| NPI | 1063852903 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: RI ODTG00602) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MA 4968) |
| 152W00000X Optometrist (Licence: NY 008104) | |
| Enumeration Date | 2013-06-25 |
| Last Update Date | 2015-12-04 |