Healthcare Provider Details

I. General information

NPI: 1659899615
Provider Name (Legal Business Name): MAURICIO DURAN RDN, CDN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 BAINBRIDGE AVE FL 2
BRONX NY
10467-2404
US

IV. Provider business mailing address

20915 18TH AVE APT 4H
BAYSIDE NY
11360-1407
US

V. Phone/Fax

Practice location:
  • Phone: 866-633-8255
  • Fax:
Mailing address:
  • Phone: 347-417-2424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number009038
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: