| NPI | 1336213024 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: PA OE005601P) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: GA OPT001727) |
| 152W00000X Optometrist (Licence: OH 3243T1658) | |
| Enumeration Date | 2006-11-17 |
| Last Update Date | 2009-08-03 |