Provider Demographics
NPI:1720701071
Name:SUGUITAN, JOHAN D (RD, LDN)
Entity Type:Individual
Prefix:
First Name:JOHAN
Middle Name:D
Last Name:SUGUITAN
Suffix:
Gender:M
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8443 DRAKE AVE
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-2817
Mailing Address - Country:US
Mailing Address - Phone:773-396-9563
Mailing Address - Fax:
Practice Address - Street 1:5025 N PAULINA ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-2772
Practice Address - Country:US
Practice Address - Phone:773-271-9040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-21
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.004251133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered