Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 152WC0802X | Optomitrist - Corneal and Contact Lenses | 4901004284 | MI |
Y | 152WC0802X | Optomitrist - Corneal and Contact Lenses | 7500TG | TX |
NPI | 1265433924 |
---|---|
Provider Name | Dr. Jill Marie Haven |
First Address | Austin, TX 78735-0046 |
Second Address | Austin, TX 78746-7422 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 03/08/2005 |
Last Update Date | 20/01/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
V04374 | (02) | MI |