| NPI | 1699791798 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: IL 046.010635) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OH 5594) |
| 152W00000X Optometrist (Licence: IA 002565) | |
| Enumeration Date | 2006-07-14 |
| Last Update Date | 2013-04-16 |