| NPI | 1669648374 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MO 2011020049) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: NY TUV007255) |
| 152W00000X Optometrist (Licence: IL 046010527) | |
| 152W00000X Optometrist (Licence: NY TUV007255-1) | |
| Enumeration Date | 2008-05-02 |
| Last Update Date | 2014-06-04 |