Provider Demographics
NPI:1972948354
Name:LUONGO, MAIKA (MS, RD, LDN)
Entity Type:Individual
Prefix:MRS
First Name:MAIKA
Middle Name:
Last Name:LUONGO
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 STATE ST
Mailing Address - Street 2:26TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-1827
Mailing Address - Country:US
Mailing Address - Phone:617-204-3500
Mailing Address - Fax:
Practice Address - Street 1:75 STATE ST
Practice Address - Street 2:26TH FLOOR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02109-1827
Practice Address - Country:US
Practice Address - Phone:617-204-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-30
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2826133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered