| NPI | 1336107382 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207W00000X Ophthalmology (Licence: RI 9005) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: RI 00496) |
| 207W00000X Ophthalmology (Licence: MA 79430) | |
| Enumeration Date | 2006-05-01 |
| Last Update Date | 2012-03-19 |