| NPI | 1366461246 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: FL OPC003758) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: GA OPT001988) |
| 152W00000X Optometrist (Licence: NY 006647) | |
| 152W00000X Optometrist (Licence: HI OD-599) | |
| Enumeration Date | 2006-07-19 |
| Last Update Date | 2018-06-29 |