| NPI | 1306840111 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: SD 649) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: IA 1655) |
| 152W00000X Optometrist (Licence: MO T03000) | |
| 152W00000X Optometrist (Licence: NE 1131) | |
| Enumeration Date | 2005-06-09 |
| Last Update Date | 2008-09-04 |