| NPI | 1003848433 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MI 4901002243) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: IN 18001440A) |
| Enumeration Date | 2006-07-07 |
| Last Update Date | 2013-01-14 |