| NPI | 1255887584 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MI 4901005034) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: PA OEG003141) |
| Enumeration Date | 2016-08-28 |
| Last Update Date | 2019-09-04 |