| NPI | 1356393623 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 152W00000X Optometrist (Licence: ID ODP-1006) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: WI 3442-35) |
| Enumeration Date | 2006-05-16 |
| Last Update Date | 2017-11-29 |