| NPI | 1144319955 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MT 4258) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OH 4395) |
| 152W00000X Optometrist (Licence: CO 2555) | |
| Enumeration Date | 2006-10-11 |
| Last Update Date | 2021-09-24 |