| NPI | 1598748790 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WI 1567) |
| Additional Taxonomies | 152WP0200X Optometrist, Pediatrics (Licence: WI 1567) |
| 152WV0400X Optometrist, Vision Therapy (Licence: WI 1567) | |
| Enumeration Date | 2005-11-22 |
| Last Update Date | 2008-12-16 |