| NPI | 1043596000 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: FL OPC4775) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: SC 1667) |
| 152W00000X Optometrist (Licence: GA OPT002674) | |
| Enumeration Date | 2011-10-21 |
| Last Update Date | 2014-07-26 |