| NPI | 1053864488 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: ME OPT982) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MA 5202) |
| Enumeration Date | 2016-08-02 |
| Last Update Date | 2017-11-14 |