| NPI | 1003811605 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MI 4901004014) |
| Additional Taxonomies | 152WL0500X Optometrist, Low Vision Rehabilitation (Licence: MI 4901004014) |
| Enumeration Date | 2005-06-20 |
| Last Update Date | 2025-09-11 |