| NPI | 1295746840 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: ID ODP-100217) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: GA 1869) |
| Enumeration Date | 2006-08-10 |
| Last Update Date | 2019-05-13 |