| NPI | 1073055398 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: IL 046.011072) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OR 2185D) |
| Enumeration Date | 2016-11-17 |
| Last Update Date | 2016-11-17 |