| NPI | 1104011485 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: NY 007387) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: TN 2780) |
| Enumeration Date | 2007-09-11 |
| Last Update Date | 2009-05-04 |