| NPI | 1659420289 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: TX 06679T) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: PA OEG001448) |
| Enumeration Date | 2007-01-10 |
| Last Update Date | 2011-06-07 |