Provider Demographics
NPI:1720610678
Name:MAHER, MICHAEL ROBERT (RD, MS, CDN, CSR)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ROBERT
Last Name:MAHER
Suffix:
Gender:M
Credentials:RD, MS, CDN, CSR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:282 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MERRICK
Mailing Address - State:NY
Mailing Address - Zip Code:11566-2845
Mailing Address - Country:US
Mailing Address - Phone:631-875-0672
Mailing Address - Fax:
Practice Address - Street 1:282 PARK AVE
Practice Address - Street 2:
Practice Address - City:MERRICK
Practice Address - State:NY
Practice Address - Zip Code:11566-2845
Practice Address - Country:US
Practice Address - Phone:631-875-0672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-09
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010753-01133VN1005X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal