| NPI | 1538143540 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MO TO 3339) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: KS KS 1674) |
| Enumeration Date | 2005-12-02 |
| Last Update Date | 2010-11-12 |