Provider Demographics
NPI:1942580501
Name:WATTENBERG, CLINTON HAROLD (RD)
Entity Type:Individual
Prefix:MR
First Name:CLINTON
Middle Name:HAROLD
Last Name:WATTENBERG
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 1:949 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-6158
Mailing Address - Country:US
Mailing Address - Phone:607-227-9344
Mailing Address - Fax:
Practice Address - Street 1:949 E STATE ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-6158
Practice Address - Country:US
Practice Address - Phone:607-227-9344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-26
Last Update Date:2011-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1044495133V00000X, 133VN1004X, 133VN1006X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program