| NPI | 1396733648 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WA OD00004113) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MI 4901004274) |
| Enumeration Date | 2005-10-11 |
| Last Update Date | 2023-10-06 |