| NPI | 1255317541 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: TN 3265) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OH 4572 / T1315) |
| 152W00000X Optometrist (Licence: TX 5679T) | |
| 152W00000X Optometrist (Licence: KY 1441DT) | |
| Enumeration Date | 2005-12-19 |
| Last Update Date | 2015-11-03 |