| NPI | 1104858992 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: OR 1361ATI) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: WA OD00001178) |
| 152W00000X Optometrist (Licence: AZ 1494) | |
| Enumeration Date | 2006-07-06 |
| Last Update Date | 2007-07-16 |