Healthcare Provider Details

I. General information

NPI: 1942580501
Provider Name (Legal Business Name): CLINTON HAROLD WATTENBERG RD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2011
Last Update Date: 08/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

949 E STATE ST
ITHACA NY
14850-6158
US

IV. Provider business mailing address

949 E STATE ST
ITHACA NY
14850-6158
US

V. Phone/Fax

Practice location:
  • Phone: 607-227-9344
  • Fax:
Mailing address:
  • Phone: 607-227-9344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1044495
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number1044495
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number1044495
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number1044495
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: