| NPI | 1104209642 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: CA 33413-TLG) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: AZ 2051) |
| Enumeration Date | 2015-07-01 |
| Last Update Date | 2018-02-21 |