Healthcare Provider Details

I. General information

NPI: 1003886904
Provider Name (Legal Business Name): MARTHA CZYMMEK RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 06/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4701 OGLETOWN-STANTON ROAD SUITE 1213
NEWARK DE
19713
US

IV. Provider business mailing address

PO BOX 30170
WILMINGTON DE
19805
US

V. Phone/Fax

Practice location:
  • Phone: 302-623-4550
  • Fax: 302-623-4554
Mailing address:
  • Phone: 302-623-7262
  • Fax: 302-623-7374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDN0000135
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: