| NPI | 1255333829 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WV 636D) |
| Additional Taxonomies | 208D00000X General Practice (Licence: WV 21556) |
| Enumeration Date | 2005-08-12 |
| Last Update Date | 2011-10-27 |