Provider Demographics
NPI:1053947564
Name:AZEVEDO, JOHN T (RD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:T
Last Name:AZEVEDO
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 1:9451 WINDRUNNER LN
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-4636
Mailing Address - Country:US
Mailing Address - Phone:209-604-9003
Mailing Address - Fax:
Practice Address - Street 1:9451 WINDRUNNER LN
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-4636
Practice Address - Country:US
Practice Address - Phone:916-668-9206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-16
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86023720133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered