Provider Demographics
NPI:1356580021
Name:SWEENEY, JOHN J (RD , CDN)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:J
Last Name:SWEENEY
Suffix:
Gender:M
Credentials:RD , CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 JASMINE LN
Mailing Address - Street 2:
Mailing Address - City:SOUTHOLD
Mailing Address - State:NY
Mailing Address - Zip Code:11971-3071
Mailing Address - Country:US
Mailing Address - Phone:631-765-1267
Mailing Address - Fax:
Practice Address - Street 1:930 JASMINE LN
Practice Address - Street 2:
Practice Address - City:SOUTHOLD
Practice Address - State:NY
Practice Address - Zip Code:11971-3071
Practice Address - Country:US
Practice Address - Phone:631-765-1267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-19
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001098-1133N00000X
IL721012133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY9256E1OtherMEDICARE PROVIDER NUMBER