| NPI | 1225198013 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MO 2004019126) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: IL 046009701) |
| Enumeration Date | 2006-12-11 |
| Last Update Date | 2012-02-13 |