| NPI | 1003194507 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: CO 2907) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: CA 14542TLG) |
| 152W00000X Optometrist (Licence: AZ 1976) | |
| Enumeration Date | 2011-08-01 |
| Last Update Date | 2016-11-20 |