Provider Demographics
NPI:1851057178
Name:BURCIAGA, IVON (RDN)
Entity Type:Individual
Prefix:
First Name:IVON
Middle Name:
Last Name:BURCIAGA
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 BALDWIN ST
Mailing Address - Street 2:
Mailing Address - City:RED OAK
Mailing Address - State:TX
Mailing Address - Zip Code:75154-4005
Mailing Address - Country:US
Mailing Address - Phone:469-552-3394
Mailing Address - Fax:
Practice Address - Street 1:309 BALDWIN ST
Practice Address - Street 2:
Practice Address - City:RED OAK
Practice Address - State:TX
Practice Address - Zip Code:75154-4005
Practice Address - Country:US
Practice Address - Phone:469-552-3394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-10
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT86857133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered