| NPI | 1649260142 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: TX 3001T) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: CO 1637) |
| 152W00000X Optometrist (Licence: CA 7407) | |
| 152W00000X Optometrist (Licence: WA 1462) | |
| Enumeration Date | 2005-10-26 |
| Last Update Date | 2007-07-08 |