Healthcare Provider Details

I. General information

NPI: 1295860716
Provider Name (Legal Business Name): VIDA GOUDARZI RD REGISTERED DIETIT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 11/15/2022
Certification Date: 11/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76 OAK GROVE AVE
LOS GATOS CA
95030-7049
US

IV. Provider business mailing address

76 OAK GROVE AVE
LOS GATOS CA
95030-7049
US

V. Phone/Fax

Practice location:
  • Phone: 408-205-8887
  • Fax:
Mailing address:
  • Phone: 408-205-8887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number957130
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: