| NPI | 1063460103 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: PA OEG001113) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: NJ 27TO00124800) |
| 152W00000X Optometrist (Licence: NJ 27OA00585300) | |
| Enumeration Date | 2006-05-04 |
| Last Update Date | 2012-06-06 |