| NPI | 1336252956 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MA 4114) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: CT 002487) |
| 152W00000X Optometrist (Licence: RI ODT00479) | |
| Enumeration Date | 2006-08-16 |
| Last Update Date | 2007-07-08 |