| NPI | 1225034200 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WI 1664) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: CA OPT 6649 TPA) |
| Enumeration Date | 2005-06-23 |
| Last Update Date | 2014-04-29 |