| NPI | 1558576629 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: AZ 51) |
| Additional Taxonomies | 152WP0200X Optometrist, Pediatrics (Licence: AZ 51) |
| 152WS0006X Optometrist, Sports Vision (Licence: AZ 51) | |
| Enumeration Date | 2007-05-11 |
| Last Update Date | 2007-12-26 |