Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 18003079A | IN |
NPI | 1013169069 |
---|---|
Provider Name | Julia L Blank |
First Address | Indianapolis, IN 46228-2846 |
Second Address | Indianapolis, IN 46228-2846 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/10/2008 |
Last Update Date | 21/10/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
200291140 | (05) | IN |