Provider Demographics
NPI:1306462650
Name:DAVIS, MARK ALBERT (RDLDN)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:ALBERT
Last Name:DAVIS
Suffix:
Gender:M
Credentials:RDLDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:810 CLAIRTON BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15236-5511
Mailing Address - Country:US
Mailing Address - Phone:412-650-1179
Mailing Address - Fax:412-650-1171
Practice Address - Street 1:810 CLAIRTON BLVD STE 400
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15236-5511
Practice Address - Country:US
Practice Address - Phone:412-650-1170
Practice Address - Fax:412-650-1171
Is Sole Proprietor?:No
Enumeration Date:2020-06-23
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN000962133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered