Provider Demographics
NPI:1669572731
Name:BOCCARDO, MARY K (RD CDN)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:K
Last Name:BOCCARDO
Suffix:
Gender:F
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 1:4900 BROAD RD
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13215-2265
Mailing Address - Country:US
Mailing Address - Phone:315-492-5152
Mailing Address - Fax:315-492-5002
Practice Address - Street 1:4900 BROAD RD
Practice Address - Street 2:HEALTH EDUCATION DEPT, POB SOUTH, SUITE 1F
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13215-2265
Practice Address - Country:US
Practice Address - Phone:315-492-5152
Practice Address - Fax:315-492-5002
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY918980133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered