Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 046.011274 | IL |
N | 152WC0802X | Optomitrist - Corneal and Contact Lenses | 046.011274 | IL |
NPI | 1063641538 |
---|---|
Provider Name | Justin Timothy Kwan |
First Address | Niles, IL 60714-4548 |
Second Address | Niles, IL 60714-4548 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/07/2009 |
Last Update Date | 18/05/2019 |