| NPI | 1588722011 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: VA 0618001372) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MD TA1854) |
| Enumeration Date | 2006-12-05 |
| Last Update Date | 2007-07-08 |