| NPI | 1114278447 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: ID ODP-100254) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MA 4943) |
| Enumeration Date | 2012-09-26 |
| Last Update Date | 2021-07-23 |