| NPI | 1609868868 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: AZ 879) |
| Additional Taxonomies | 152WC0802X Optometrist, Corneal and Contact Management (Licence: AZ 879) |
| 152WP0200X Optometrist, Pediatrics (Licence: AZ 879) | |
| Enumeration Date | 2005-08-15 |
| Last Update Date | 2015-11-17 |