| NPI | 1154379766 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: NC 1477) |
| Additional Taxonomies | 152WC0802X Optometrist, Corneal and Contact Management (Licence: NC 1477) |
| 152WL0500X Optometrist, Low Vision Rehabilitation (Licence: NC 1477) | |
| Enumeration Date | 2006-05-05 |
| Last Update Date | 2011-11-22 |