| NPI | 1114948734 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MN 3070) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: UT 6246453-9934) |
| 152WC0802X Optometrist, Corneal and Contact Management (Licence: MN 3070) | |
| Enumeration Date | 2006-07-21 |
| Last Update Date | 2012-07-19 |