Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0106X | Oral and Maxillofacial Pathology | 019023548 | IL |
NPI | 1700862877 |
---|---|
Provider Name | Dr. David Efaw |
First Address | Bloomington, IL 61701-3515 |
Second Address | Bloomington, IL 61701-3515 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/12/2005 |
Last Update Date | 01/07/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
BB9276278 | DEA (01) | IL |
U66652 | (02) | IL |