| NPI | 1619970985 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: OH 5991) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: TX 5429T) |
| Enumeration Date | 2005-05-31 |
| Last Update Date | 2015-06-08 |