| NPI | 1124079223 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: SD 583) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MN 2813) |
| Enumeration Date | 2006-05-13 |
| Last Update Date | 2008-05-19 |