Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 007264 | NY |
NPI | 1164546065 |
---|---|
Provider Name | Eduard Shimanov |
First Address | Fresh Meadows, NY 11365-3538 |
Second Address | Oakland Gardens, NY 11364-2947 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/03/2007 |
Last Update Date | 08/07/2007 |