| NPI | 1104992585 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MO 2010037748) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: FL OPC4121) |
| Enumeration Date | 2006-11-28 |
| Last Update Date | 2019-11-14 |