| NPI | 1417015215 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: AZ AZ 1685) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MI 4901003957) |
| 152W00000X Optometrist (Licence: GA OPT002547) | |
| Enumeration Date | 2006-12-05 |
| Last Update Date | 2010-10-16 |