| NPI | 1063555316 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: CT CT2279) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: NY T-005145-1) |
| Enumeration Date | 2007-02-15 |
| Last Update Date | 2007-07-08 |