Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | C 3586 | NY |
NPI | 1043527245 |
---|---|
Provider Name | Mark David Benton |
First Address | Cooperstown, NY 13326-1301 |
Second Address | Cooperstown, NY 13326-1301 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/09/2010 |
Last Update Date | 09/09/2010 |