| NPI | 1558617993 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MO 2012017342) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: KS 1915) |
| Enumeration Date | 2012-08-02 |
| Last Update Date | 2020-01-09 |