| NPI | 1578623013 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MD TA1030) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: VA 0618000579) |
| 152W00000X Optometrist (Licence: DC OP577) | |
| Enumeration Date | 2006-12-12 |
| Last Update Date | 2012-12-06 |