| NPI | 1649617614 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MN 3330) |
| Additional Taxonomies | 152WC0802X Optometrist, Corneal and Contact Management (Licence: MN 3330) |
| 152WP0200X Optometrist, Pediatrics (Licence: MN 3330) | |
| Enumeration Date | 2013-05-30 |
| Last Update Date | 2013-05-31 |