Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 4901004130 | MI |
NPI | 1013156124 |
---|---|
Provider Name | Bradley James Runyon |
First Address | Marshall, MI 49068-1446 |
Second Address | Marshall, MI 49068-1446 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/02/2009 |
Last Update Date | 19/11/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1013156124 | (05) | MI |
X48437 | (02) | MI |