| NPI | 1629019682 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: PA OEG000298) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: NJ 27OA00563700) |
| 152W00000X Optometrist (Licence: DE I3-0001257) | |
| Enumeration Date | 2006-06-09 |
| Last Update Date | 2010-09-08 |