| NPI | 1104942358 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MO 2013040186) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: CA 7816 TPG) |
| Enumeration Date | 2007-03-21 |
| Last Update Date | 2015-10-22 |