| NPI | 1588942569 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MI 4901004793) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: PA OEG002510) |
| 152W00000X Optometrist (Licence: ME OPT930) | |
| Enumeration Date | 2011-07-25 |
| Last Update Date | 2016-11-30 |