| NPI | 1396120234 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: ID ODP-100357) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: CA OPT 15241 TLG) |
| Enumeration Date | 2015-07-21 |
| Last Update Date | 2016-10-21 |