Provider Demographics
NPI:1821318759
Name:VERIK, MARY JANE (RD LD)
Entity Type:Individual
Prefix:MRS
First Name:MARY JANE
Middle Name:
Last Name:VERIK
Suffix:
Gender:F
Credentials:RD LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2029 MUSTANG DR.
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60565
Mailing Address - Country:US
Mailing Address - Phone:630-753-9270
Mailing Address - Fax:630-753-9271
Practice Address - Street 1:2029 MUSTANG DR.
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60565
Practice Address - Country:US
Practice Address - Phone:630-753-9270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-02
Last Update Date:2010-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL#164-00050133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered