| NPI | 1174529978 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: OH 5299 T2208) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: ID ODP-100042) |
| Enumeration Date | 2005-06-27 |
| Last Update Date | 2019-01-22 |