| NPI | 1619049228 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WA OD00003957) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: ID ODP-1014) |
| Enumeration Date | 2006-11-15 |
| Last Update Date | 2011-12-01 |