Provider Demographics
NPI:1649842006
Name:ZAMORA, ANTHONY JOHN
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:JOHN
Last Name:ZAMORA
Suffix:
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 1:1420 S 500 W
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84115-5149
Mailing Address - Country:US
Mailing Address - Phone:865-210-2628
Mailing Address - Fax:
Practice Address - Street 1:1420 S 500 W
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115-5149
Practice Address - Country:US
Practice Address - Phone:865-210-2628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11799532-4901133VN1501X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133VN1501XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Sports DieteticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
86097524OtherCOMMISSION ON DIETETIC REGISTRATION