| NPI | 1114011913 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MO 2009002132) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: IA 1520T) |
| Enumeration Date | 2006-10-03 |
| Last Update Date | 2010-09-01 |