| NPI | 1265439723 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: CO 2081) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: VT 030.0069859) |
| Enumeration Date | 2005-06-30 |
| Last Update Date | 2011-11-10 |