Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1700X | Ocularist | 5001000008 | MI |
NPI | 1386667517 |
---|---|
Provider Name | Mr. Terrence Norton Donovan |
First Address | Livonia, MI 48150-1540 |
Second Address | Livonia, MI 48150-1540 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/07/2006 |
Last Update Date | 19/11/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
5090486 | (05) | MI |
540Q20959 | BLUE CROSS (01) | MI |