| NPI | 1285862110 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: VA 0618001846) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MD TA2152) |
| Enumeration Date | 2009-06-30 |
| Last Update Date | 2011-10-19 |