Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 688 | CT |
NPI | 1154702041 |
---|---|
Provider Name | Donat Jutras |
First Address | Bristol, CT 06010-3927 |
Second Address | Bristol, CT 06010-3927 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 16/06/2015 |
Last Update Date | 16/06/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1871690131 | (05) | CT |