| NPI | 1225289952 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: SC 1529) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: PA OEG002130) |
| 152W00000X Optometrist (Licence: NC 2166) | |
| Enumeration Date | 2008-09-30 |
| Last Update Date | 2015-01-07 |