Healthcare Provider Details

I. General information

NPI: 1235625054
Provider Name (Legal Business Name): REETU NIGAM RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/04/2018
Last Update Date: 12/16/2019
Certification Date: 12/16/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 KEARNEY ST
FREMONT CA
94538-2299
US

IV. Provider business mailing address

325 DISTEL CIR
LOS ALTOS CA
94022-1408
US

V. Phone/Fax

Practice location:
  • Phone: 510-498-2184
  • Fax:
Mailing address:
  • Phone: 650-934-7177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1109379
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: