| NPI | 1063741569 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: OH 5920) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: SC 1581) |
| 152W00000X Optometrist (Licence: KY 1947DT) | |
| Enumeration Date | 2009-12-11 |
| Last Update Date | 2015-06-05 |