| NPI | 1679603096 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: FL OPC3173) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: CT 002443) |
| 152W00000X Optometrist (Licence: MA 4007) | |
| 152W00000X Optometrist (Licence: RI ODTA00541) | |
| Enumeration Date | 2007-03-06 |
| Last Update Date | 2010-03-24 |