Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1700X | Ocularist | UNLICENSED STATE | MS |
NPI | 1316004039 |
---|---|
Provider Name | Mr. Charles Edward Anderson III |
First Address | Jackson, MS 39211-5555 |
Second Address | Jackson, MS 39211-5555 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/01/2007 |
Last Update Date | 12/12/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00089008 | (05) | MS |