Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 046011071 | IL |
NPI | 1003358466 |
---|---|
Provider Name | Dr. Mary Gouris |
First Address | Chicago, IL 60601-7757 |
Second Address | Chicago, IL 60601-7757 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/11/2016 |
Last Update Date | 15/11/2016 |