| NPI | 1215120696 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: ID ODP-100148) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: UT 66612099934) |
| Enumeration Date | 2007-08-20 |
| Last Update Date | 2019-09-10 |