Provider Demographics
NPI:1336412402
Name:AZCARATE, JAVIER EDUARDO (RD)
Entity type:Individual
Prefix:
First Name:JAVIER
Middle Name:EDUARDO
Last Name:AZCARATE
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 MARTHA BERRY BLVD NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1625
Mailing Address - Country:US
Mailing Address - Phone:706-295-5331
Mailing Address - Fax:
Practice Address - Street 1:172 THREE RIVERS DR NE
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-4999
Practice Address - Country:US
Practice Address - Phone:706-234-6905
Practice Address - Fax:706-291-7792
Is Sole Proprietor?:No
Enumeration Date:2012-02-20
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD003853133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003129910AMedicaid
GA202I711590Medicare PIN