Provider Demographics
NPI:1972121903
Name:LANDAVERDE, MARIO E (RDN)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:E
Last Name:LANDAVERDE
Suffix:
Gender:M
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 W 96TH ST APT 8B
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-9221
Mailing Address - Country:US
Mailing Address - Phone:917-691-9776
Mailing Address - Fax:
Practice Address - Street 1:135 W 96TH ST APT 8B
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-9221
Practice Address - Country:US
Practice Address - Phone:917-691-9776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-07
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY86062371133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered