Provider Demographics
NPI:1821840695
Name:OKUNAS, ETHAN (RD)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:OKUNAS
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2903 LOCH HAVEN CT
Mailing Address - Street 2:
Mailing Address - City:IJAMSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21754-8813
Mailing Address - Country:US
Mailing Address - Phone:508-333-8639
Mailing Address - Fax:
Practice Address - Street 1:2903 LOCH HAVEN CT
Practice Address - Street 2:
Practice Address - City:IJAMSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21754-8813
Practice Address - Country:US
Practice Address - Phone:508-333-8639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-03
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX6437133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered