| NPI | 1063820306 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: KS 1992) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MO 2014020365) |
| Enumeration Date | 2014-07-30 |
| Last Update Date | 2018-03-17 |