Provider Demographics
NPI:1780323956
Name:FIACCO, DEREK MICHAEL (RD)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:MICHAEL
Last Name:FIACCO
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 1:83 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:CORNING
Mailing Address - State:NY
Mailing Address - Zip Code:14830-3103
Mailing Address - Country:US
Mailing Address - Phone:607-329-3997
Mailing Address - Fax:
Practice Address - Street 1:3250 W 66TH ST
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2522
Practice Address - Country:US
Practice Address - Phone:320-309-8913
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-03
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty