| NPI | 1003079625 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: NC 2133) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: PA OEG002069) |
| Enumeration Date | 2008-07-03 |
| Last Update Date | 2018-03-21 |