| NPI | 1043207343 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: CO 2456) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OH 4077 T1986) |
| 152W00000X Optometrist (Licence: VI 51) | |
| Enumeration Date | 2005-10-02 |
| Last Update Date | 2014-04-24 |