| NPI | 1114200847 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: KY KY2047DT) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MD TA2226) |
| Enumeration Date | 2011-09-20 |
| Last Update Date | 2018-12-17 |