| NPI | 1376831990 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MA 5011) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: TX 7826TG) |
| Enumeration Date | 2011-07-17 |
| Last Update Date | 2014-08-19 |