| NPI | 1013999457 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WI 1551) |
| Additional Taxonomies | 152WC0802X Optometrist Corneal and Contact Management (Licence: WI 1551) |
| 152WS0006X Optometrist Sports Vision (Licence: WI 1551) | |
| Enumeration Date | 2005-11-18 |
| Last Update Date | 2008-12-16 |