Healthcare Provider Details

I. General information

NPI: 1609189059
Provider Name (Legal Business Name): JOHN DODD RD,CSR,LD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2010
Last Update Date: 07/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 SANDCASTLE DR
ORMOND BEACH FL
32176-4156
US

IV. Provider business mailing address

123 SANDCASTLE DR
ORMOND BEACH FL
32176-4156
US

V. Phone/Fax

Practice location:
  • Phone: 386-441-2090
  • Fax:
Mailing address:
  • Phone: 386-441-2090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License NumberND 2189
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: