| NPI | 1164506713 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: VA 0618001613) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MD TA2010) |
| 152W00000X Optometrist (Licence: DC OP1000135) | |
| Enumeration Date | 2006-10-24 |
| Last Update Date | 2016-12-29 |