Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 008765 | NY |
NPI | 1023325107 |
---|---|
Provider Name | Mr. Howard Randolph Ellison II |
First Address | Bronx, NY 10468-5408 |
Second Address | Bronx, NY 10468-5408 |
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 |