Provider Demographics
NPI:1962032045
Name:SANTOSO, ERVA (RDN)
Entity type:Individual
Prefix:
First Name:ERVA
Middle Name:
Last Name:SANTOSO
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11400 EDGEMERE BLVD APT 3113
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-2426
Mailing Address - Country:US
Mailing Address - Phone:718-360-7472
Mailing Address - Fax:
Practice Address - Street 1:18511 HIGHLANDER MEDICS ST
Practice Address - Street 2:
Practice Address - City:FORT BLISS
Practice Address - State:TX
Practice Address - Zip Code:79906-5327
Practice Address - Country:US
Practice Address - Phone:718-360-7472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-17
Last Update Date:2025-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI205-LD133V00000X
1072186133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered