| NPI | 1396743472 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MO 2004016908) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: KS 1680) |
| Enumeration Date | 2005-07-12 |
| Last Update Date | 2019-07-08 |