| NPI | 1346347457 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MA 3139) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: ID ODP-100055) |
| Enumeration Date | 2006-09-20 |
| Last Update Date | 2011-05-26 |