| NPI | 1255587242 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MO 2008017076) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: KS 1811) |
| Enumeration Date | 2008-08-11 |
| Last Update Date | 2016-12-29 |