| NPI | 1053454835 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: KY 2012DT) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MI 4901003688) |
| 152W00000X Optometrist (Licence: CA OPT14360TPG) | |
| Enumeration Date | 2007-02-14 |
| Last Update Date | 2016-09-20 |