| NPI | 1104113208 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MI 4901004651) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OH 6033/T2948) |
| Enumeration Date | 2011-07-09 |
| Last Update Date | 2012-11-20 |