| NPI | 1548468580 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: ID ODP100163) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OR 3254AT) |
| Enumeration Date | 2007-07-10 |
| Last Update Date | 2010-10-07 |