| NPI | 1013003474 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: PA OE-007169-T) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: VA 0601001706) |
| Enumeration Date | 2006-10-05 |
| Last Update Date | 2007-07-08 |