| NPI | 1376650903 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: NC 1271) |
| Additional Taxonomies | 152WC0802X Optometrist Corneal and Contact Management (Licence: NC 1271) |
| 152WP0200X Optometrist Pediatrics (Licence: NC 1271) | |
| 152WS0006X Optometrist Sports Vision (Licence: NC 1271) | |
| Enumeration Date | 2006-08-23 |
| Last Update Date | 2010-07-27 |