| NPI | 1245255769 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MD TA1176) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: PA OET008917) |
| 152W00000X Optometrist (Licence: VA 0618001378) | |
| Enumeration Date | 2006-07-13 |
| Last Update Date | 2007-07-08 |