| NPI | 1154332203 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: KY 1663DT) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: IN 18003383A) |
| Enumeration Date | 2006-08-11 |
| Last Update Date | 2020-08-07 |