| NPI | 1104129162 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: TX 7320) |
| Additional Taxonomies | 152WC0802X Optometrist, Corneal and Contact Management (Licence: TX 7320) |
| 152WS0006X Optometrist, Sports Vision (Licence: TX 7320) | |
| Enumeration Date | 2010-12-14 |
| Last Update Date | 2010-12-14 |