| NPI | 1003988197 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: OH 5593 T2507) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: SC 1625) |
| Enumeration Date | 2006-11-14 |
| Last Update Date | 2020-12-29 |