Provider Demographics
NPI:1801509930
Name:ZACARIAS, IVAN (RD, IBCLC)
Entity type:Individual
Prefix:MR
First Name:IVAN
Middle Name:
Last Name:ZACARIAS
Suffix:
Gender:M
Credentials:RD, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3877 N 7TH ST FL 4
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-5072
Mailing Address - Country:US
Mailing Address - Phone:480-407-4280
Mailing Address - Fax:
Practice Address - Street 1:3807 N 7TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-5005
Practice Address - Country:US
Practice Address - Phone:480-407-4280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-04
Last Update Date:2025-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZL-152783174N00000X
AZ86064802133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No174N00000XOther Service ProvidersLactation Consultant, Non-RN
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherNONE AVAILABLE