| NPI | 1558339135 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: GA GA-OPT000856) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: WV 920-OD) |
| Enumeration Date | 2006-03-09 |
| Last Update Date | 2015-05-05 |