| NPI | 1003808395 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: TX 5621TG) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MN 2689) |
| Enumeration Date | 2005-08-22 |
| Last Update Date | 2009-10-28 |