| NPI | 1689656712 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: NJ 270A00368900) |
| Additional Taxonomies | 152WV0400X Optometrist Vision Therapy (Licence: NJ 27T000071700) |
| 156F00000X Technician/Technologist (Licence: NJ 27OA00368900) | |
| Enumeration Date | 2005-11-15 |
| Last Update Date | 2012-09-18 |