Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225000000X | Orthotic Fitter |
NPI | 1093840613 |
---|---|
Provider Name | Michael Darryl Hoffman |
First Address | Willowbrook, IL 60527-5607 |
Second Address | Willowbrook, IL 60527-5607 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/02/2007 |
Last Update Date | 05/12/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
01623063 | BLUE CROSS PROVIDER NUMBE (01) | IL |