| NPI | 1043205834 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152WC0802X Optometrist Corneal and Contact Management (Licence: MA 2670 TP) |
| Additional Taxonomies | 152WS0006X Optometrist Sports Vision (Licence: MA 2670 TP) |
| Enumeration Date | 2005-09-16 |
| Last Update Date | 2014-04-07 |