Provider Demographics
NPI:1902148646
Name:VENABLE, DORIAN II
Entity Type:Individual
Prefix:
First Name:DORIAN
Middle Name:
Last Name:VENABLE
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX PH
Mailing Address - Street 2:
Mailing Address - City:CHINLE
Mailing Address - State:AZ
Mailing Address - Zip Code:86503-8000
Mailing Address - Country:US
Mailing Address - Phone:928-674-7166
Mailing Address - Fax:928-674-7705
Practice Address - Street 1:NAVAJO ROUTE 64
Practice Address - Street 2:
Practice Address - City:TSAILE
Practice Address - State:AZ
Practice Address - Zip Code:86556
Practice Address - Country:US
Practice Address - Phone:928-724-3612
Practice Address - Fax:928-724-3671
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-20
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT07319133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
933052OtherCDR