| NPI | 1205979242 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: GA 881) |
| Additional Taxonomies | 152WC0802X Optometrist, Corneal and Contact Management (Licence: GA 881) |
| 152WX0102X Optometrist, Occupational Vision (Licence: GA 881) | |
| Enumeration Date | 2007-02-15 |
| Last Update Date | 2007-07-08 |