| NPI | 1578508933 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: NC 2002) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: PA OEG001701) |
| Enumeration Date | 2006-06-19 |
| Last Update Date | 2014-06-10 |