| NPI | 1396830840 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: NC 2026) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: VA 0618001599) |
| Enumeration Date | 2006-10-03 |
| Last Update Date | 2018-03-17 |