| NPI | 1013962828 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: UT 1126319934) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: UT 1126318908) |
| Enumeration Date | 2006-05-23 |
| Last Update Date | 2012-08-01 |