| NPI | 1639266265 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: AZ 1553) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MI 4901002888) |
| Enumeration Date | 2006-10-06 |
| Last Update Date | 2007-07-08 |