| NPI | 1295737625 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: AZ 1741) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: SC 1322) |
| Enumeration Date | 2005-08-15 |
| Last Update Date | 2012-09-07 |