| NPI | 1053308767 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: CO 0003037) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: TX 05658T) |
| Enumeration Date | 2005-09-29 |
| Last Update Date | 2020-06-09 |