| NPI | 1528051802 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MO 2001023319) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: KS 1635) |
| Enumeration Date | 2005-08-23 |
| Last Update Date | 2007-12-06 |