| NPI | 1487634929 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MI 4901002484) |
| Additional Taxonomies | 152WC0802X Optometrist Corneal and Contact Management (Licence: MI 4901002484) |
| 152WP0200X Optometrist Pediatrics (Licence: MI 4901002484) | |
| Enumeration Date | 2006-01-19 |
| Last Update Date | 2007-07-08 |