| NPI | 1285621706 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: VA 0618000476) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OH OPT.3871-THER) |
| Enumeration Date | 2005-09-30 |
| Last Update Date | 2018-01-24 |