Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 046.011258 | IL |
NPI | 1013483783 |
---|---|
Provider Name | Dr. Eric Birky |
First Address | Bloomington, IL 61704-3596 |
Second Address | Bloomington, IL 61704-3596 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/10/2018 |
Last Update Date | 19/10/2018 |