| NPI | 1023241437 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MO 2010020480) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: IL 046.010363) |
| Enumeration Date | 2009-09-01 |
| Last Update Date | 2014-01-07 |