| NPI | 1528055043 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: FL OPC3934) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: ND ND480) |
| 152W00000X Optometrist (Licence: CA CA8633T) | |
| Enumeration Date | 2005-09-30 |
| Last Update Date | 2011-11-14 |