Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207YX0905X | Otolaryngology/Facial Plastic Surgery | 5101023492 | MI |
N | 207YX0905X | Otolaryngology/Facial Plastic Surgery | 5315087309 | MI |
NPI | 1053846238 |
---|---|
Provider Name | Eytan Keidar |
First Address | Pontiac, MI 48342-2217 |
Second Address | Pontiac, MI 48342-2217 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/04/2017 |
Last Update Date | 27/06/2017 |