| NPI | 1174691513 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: OH 3611 T476) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: WI 1872 035) |
| Enumeration Date | 2006-12-02 |
| Last Update Date | 2022-05-27 |