| NPI | 1376680983 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WA OD00001312) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: ID 0DP-603) |
| Enumeration Date | 2007-01-31 |
| Last Update Date | 2008-05-23 |