| NPI | 1275763062 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: GA 2580) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OH 5872) |
| Enumeration Date | 2009-07-15 |
| Last Update Date | 2011-03-08 |