| NPI | 1063526432 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: UT 4740887-9934) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: UT 4740887-8904) |
| Enumeration Date | 2006-08-19 |
| Last Update Date | 2011-07-19 |