| NPI | 1649336637 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: OH OPT 6529) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: WI 2482-035) |
| Enumeration Date | 2006-12-28 |
| Last Update Date | 2017-04-21 |