| NPI | 1528095841 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: SC 1410) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: WV 1019-OD) |
| 152W00000X Optometrist (Licence: GA OPT002380) | |
| Enumeration Date | 2006-06-26 |
| Last Update Date | 2016-08-02 |