| NPI | 1548212673 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MI 4901002690) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OH 4453 T1109) |
| Enumeration Date | 2006-05-17 |
| Last Update Date | 2009-09-29 |