| NPI | 1083739387 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: LA 1546-581T) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: PA OEG001889) |
| Enumeration Date | 2007-03-19 |
| Last Update Date | 2016-02-19 |