| NPI | 1194906883 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: TN OD0000002781) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: NY TUV007223) |
| 152W00000X Optometrist (Licence: GA OP002631) | |
| Enumeration Date | 2007-11-21 |
| Last Update Date | 2013-06-27 |