| NPI | 1255397329 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MN 2759) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OH 4725) |
| 152W00000X Optometrist (Licence: OH T1529) | |
| 152W00000X Optometrist (Licence: TN 1777) | |
| Enumeration Date | 2006-04-26 |
| Last Update Date | 2020-05-04 |