| NPI | 1013991454 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MO T02419) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: KS 1174-3) |
| Enumeration Date | 2005-11-30 |
| Last Update Date | 2010-07-12 |