| NPI | 1043290562 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MO TO3192) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: KS 1439) |
| Enumeration Date | 2006-01-19 |
| Last Update Date | 2010-11-05 |