| NPI | 1124025879 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MO 168620) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: KS 1608) |
| Enumeration Date | 2005-07-07 |
| Last Update Date | 2007-07-19 |