| NPI | 1720194632 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: UT 1109189934) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: ID ODP607) |
| Enumeration Date | 2006-08-22 |
| Last Update Date | 2012-02-16 |