| NPI | 1124004338 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: UT 110978-9934) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: NC 1074) |
| Enumeration Date | 2005-12-20 |
| Last Update Date | 2018-01-31 |