Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | MI |
NPI | 1194866004 |
---|---|
Provider Name | Mr. Michael N Brodoski |
First Address | Livonia, MI 48154 |
Second Address | Livonia, MI 48154 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/02/2007 |
Last Update Date | 01/12/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
540220276 | BCBS (01) | MI |