| NPI | 1366514309 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: PA 4976P) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OH 3165T405) |
| Enumeration Date | 2006-11-14 |
| Last Update Date | 2007-07-08 |