Healthcare Provider Details

I. General information

NPI: 1285501411
Provider Name (Legal Business Name): ELLIOT DAVID MEZERA BS, RD, LD, CD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2025
Last Update Date: 10/22/2025
Certification Date: 10/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2430 NICOLLET AVE
MINNEAPOLIS MN
55404-3461
US

IV. Provider business mailing address

6304 W 39TH ST
MINNEAPOLIS MN
55416-2705
US

V. Phone/Fax

Practice location:
  • Phone: 612-871-7443
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number3067-29
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number3820
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: