Provider Demographics
NPI:1215354535
Name:MAHJOOB, ROUDABAK (RD)
Entity type:Individual
Prefix:
First Name:ROUDABAK
Middle Name:
Last Name:MAHJOOB
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2740 HERNDON AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611-6813
Mailing Address - Country:US
Mailing Address - Phone:559-299-4264
Mailing Address - Fax:559-299-1421
Practice Address - Street 1:2740 HERNDON AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611-6813
Practice Address - Country:US
Practice Address - Phone:559-299-4264
Practice Address - Fax:559-299-1421
Is Sole Proprietor?:No
Enumeration Date:2014-03-25
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1105835133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered