| NPI | 1083670616 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: AZ 1200) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: AZ AZ1200) |
| Enumeration Date | 2006-04-22 |
| Last Update Date | 2018-04-04 |