Healthcare Provider Details

I. General information

NPI: 1740697861
Provider Name (Legal Business Name): GIOVANNI MARCOS RD LD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2014
Last Update Date: 07/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3661 S MIAMI AVE 402
MIAMI FL
33133-4236
US

IV. Provider business mailing address

7633 SW 62ND AVE
SOUTH MIAMI FL
33143-4906
US

V. Phone/Fax

Practice location:
  • Phone: 305-219-5200
  • Fax:
Mailing address:
  • Phone: 305-219-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberND 5340
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberND 5340
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License NumberND 5340
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License NumberND 5340
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: