| NPI | 1174584502 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: SC 1407) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: FL OPC2027) |
| Enumeration Date | 2006-03-28 |
| Last Update Date | 2011-10-25 |