| NPI | 1689680886 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MO 2012011384) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: IL 046-007659) |
| 152W00000X Optometrist (Licence: GA OPT002155) | |
| Enumeration Date | 2006-07-31 |
| Last Update Date | 2012-08-12 |