| NPI | 1063634657 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: ME OPT796TA) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: PA OE007657P) |
| 152W00000X Optometrist (Licence: NM OP2470) | |
| 152W00000X Optometrist (Licence: ME OPT796) | |
| Enumeration Date | 2007-05-03 |
| Last Update Date | 2013-09-03 |