| NPI | 1598742561 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: ID ODP 100117) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: CO 2440) |
| Enumeration Date | 2005-12-29 |
| Last Update Date | 2008-02-19 |