| NPI | 1164424941 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: AZ 1394) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OH 2755) |
| Enumeration Date | 2005-08-11 |
| Last Update Date | 2007-07-08 |