Provider Demographics
NPI:1841974300
Name:DUBROVSKY-RAZAM, ILANA (RDN)
Entity type:Individual
Prefix:
First Name:ILANA
Middle Name:
Last Name:DUBROVSKY-RAZAM
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:428 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07079-1832
Mailing Address - Country:US
Mailing Address - Phone:917-399-0548
Mailing Address - Fax:
Practice Address - Street 1:428 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:SOUTH ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07079-1832
Practice Address - Country:US
Practice Address - Phone:917-399-0548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered