| NPI | 1417019019 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: DC 0P1000115) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: VA 0618000015) |
| Enumeration Date | 2006-12-14 |
| Last Update Date | 2007-07-08 |