| NPI | 1104816743 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: UT 1130289934) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: UT 1130288904) |
| Enumeration Date | 2005-10-25 |
| Last Update Date | 2007-07-08 |