| NPI | 1659372696 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: VT 0300000292) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: NY 56-005641) |
| Enumeration Date | 2005-08-01 |
| Last Update Date | 2011-08-22 |