Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1700X | Ocularist | 171733 | IL |
NPI | 1922432731 |
---|---|
Provider Name | Mr. Magdy Mina |
First Address | Downers Grove, IL 60515 |
Second Address | Downers Grove, IL 60515 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/08/2013 |
Last Update Date | 28/08/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
171733 | OPTICIANS LICENSE (01) | IL |