| NPI | 1124010194 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MO TO2782) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: KS 1580) |
| Enumeration Date | 2005-08-16 |
| Last Update Date | 2024-09-09 |