| NPI | 1336224542 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WV 833OD) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: VA 0618000554) |
| 152W00000X Optometrist (Licence: MD TA0950) | |
| Enumeration Date | 2006-10-26 |
| Last Update Date | 2007-07-08 |