| NPI | 1073553111 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: CA 5998T) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: WA 2004) |
| 152W00000X Optometrist (Licence: TN 1981) | |
| 152W00000X Optometrist (Licence: AZ 23) | |
| Enumeration Date | 2006-06-07 |
| Last Update Date | 2007-07-12 |