Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 0088961 | NY |
NPI | 1063759082 |
---|---|
Provider Name | Mr. Ilya Davidson |
First Address | Brooklyn, NY 11201-5852 |
Second Address | Brooklyn, NY 11201-5852 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/01/2013 |
Last Update Date | 10/01/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1760727101 | BUSINESS NPI (01) | NY |