| NPI | 1205831245 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MI 4901002418) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OH 3071T456) |
| Enumeration Date | 2005-06-16 |
| Last Update Date | 2009-02-16 |