| NPI | 1467644229 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: TX 8094T) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: CO 2613) |
| 152W00000X Optometrist (Licence: MT 805) | |
| Enumeration Date | 2007-08-15 |
| Last Update Date | 2012-10-17 |