| NPI | 1104019645 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207W00000X Ophthalmology (Licence: LA MD.203170) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 207W00000X Ophthalmology (Licence: IA 37815) | |
| Enumeration Date | 2007-08-18 |
| Last Update Date | 2011-08-10 |