| NPI | 1740248095 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: KS 1555) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: IA 1779) |
| 152W00000X Optometrist (Licence: WI 1885) | |
| Enumeration Date | 2006-05-03 |
| Last Update Date | 2007-07-08 |