Provider Demographics
NPI:1124649306
Name:MORTILLARO, LOURDES CASTRO (RDN)
Entity type:Individual
Prefix:
First Name:LOURDES
Middle Name:CASTRO
Last Name:MORTILLARO
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 FURMAN ST APT 601
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-7083
Mailing Address - Country:US
Mailing Address - Phone:305-586-1285
Mailing Address - Fax:
Practice Address - Street 1:90 FURMAN ST APT 601
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-7083
Practice Address - Country:US
Practice Address - Phone:305-586-1285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-29
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
No133VN1201XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Obesity and Weight Management
No133VN1501XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Sports Dietetics