| NPI | 1598831075 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MD TA2030) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: SC 1469) |
| 152W00000X Optometrist (Licence: GA OPT002368) | |
| Enumeration Date | 2006-11-28 |
| Last Update Date | 2013-01-25 |