| NPI | 1700948981 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: ID ODP-100320) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MT mt775) |
| Enumeration Date | 2006-12-14 |
| Last Update Date | 2018-05-14 |