| NPI | 1134578461 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: DE I3-0001393) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: PA OEG003188) |
| 152W00000X Optometrist (Licence: NJ 27OA00667000) | |
| Enumeration Date | 2016-06-07 |
| Last Update Date | 2018-02-27 |