| NPI | 1619951274 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MO TO2404) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: AZ 582) |
| Enumeration Date | 2005-12-06 |
| Last Update Date | 2008-04-30 |