| NPI | 1043230675 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MO T02949) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: KS 1311) |
| Enumeration Date | 2006-07-19 |
| Last Update Date | 2015-04-13 |