Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213E00000X | Podiatrist | CPO03980 | |
Y | 222Z00000X | Podiatrist | CPO03980 | |
N | 224P00000X | Prosthetist | CPO03980 |
NPI | 1174025068 |
---|---|
Provider Name | Jack E. Soulis |
First Address | Duarte, CA 91010-1780 |
Second Address | Duarte, CA 91010-1780 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/03/2018 |
Last Update Date | 06/03/2018 |