Provider Demographics
NPI:1104488220
Name:MAMEROW, MADONNA M (PHD, RDN, LD)
Entity type:Individual
Prefix:DR
First Name:MADONNA
Middle Name:M
Last Name:MAMEROW
Suffix:
Gender:F
Credentials:PHD, RDN, LD
Other - Prefix:DR
Other - First Name:DONNA
Other - Middle Name:M
Other - Last Name:VICTOR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD, RD, LD
Mailing Address - Street 1:PO BOX 433
Mailing Address - Street 2:
Mailing Address - City:GALVESTON
Mailing Address - State:TX
Mailing Address - Zip Code:77553-0433
Mailing Address - Country:US
Mailing Address - Phone:281-436-9668
Mailing Address - Fax:833-259-9548
Practice Address - Street 1:2600 S SHORE BLVD STE 300
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-2944
Practice Address - Country:US
Practice Address - Phone:281-436-9668
Practice Address - Fax:833-259-9548
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-28
Last Update Date:2022-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT86015133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty