Healthcare Provider Details

I. General information

NPI: 1114670338
Provider Name (Legal Business Name): WILLIAM N CIVITILLO MS RD RDN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2022
Last Update Date: 01/28/2022
Certification Date: 01/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1502 146TH ST
WHITESTONE NY
11357-3019
US

IV. Provider business mailing address

1502 146TH ST
WHITESTONE NY
11357-3019
US

V. Phone/Fax

Practice location:
  • Phone: 718-309-8718
  • Fax:
Mailing address:
  • Phone: 718-309-8718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86109420
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: