| NPI | 1528050069 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: LA LA909-230T) |
| Additional Taxonomies | 152WC0802X Optometrist, Corneal and Contact Management (Licence: LA LA909-230T) |
| 152WL0500X Optometrist, Low Vision Rehabilitation (Licence: LA LA909-230T) | |
| 152WP0200X Optometrist, Pediatrics (Licence: LA LA909-230T) | |
| 152WS0006X Optometrist, Sports Vision (Licence: LA LA909-230T) | |
| Enumeration Date | 2005-08-19 |
| Last Update Date | 2007-07-08 |