| NPI | 1568547537 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MA MA4250) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: NH NH0734) |
| Enumeration Date | 2006-10-26 |
| Last Update Date | 2008-11-23 |