| NPI | 1124029269 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MA 2881) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: NH 0421) |
| Enumeration Date | 2005-08-10 |
| Last Update Date | 2012-09-19 |