| NPI | 1609856764 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: VA 0618000445) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OH 4220) |
| Enumeration Date | 2006-01-17 |
| Last Update Date | 2018-07-13 |