| NPI | 1255643177 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MI 4901004627) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OH OPT.5943-THER) |
| Enumeration Date | 2010-07-08 |
| Last Update Date | 2016-03-27 |