| NPI | 1750300992 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: OK 2154) |
| Additional Taxonomies | 152WC0802X Optometrist Corneal and Contact Management (Licence: OK 2154) |
| 152WP0200X Optometrist Pediatrics (Licence: OK 2154) | |
| 152WS0006X Optometrist Sports Vision (Licence: OK 2154) | |
| 332H00000X Eyewear Supplier (Licence: OK 2154) | |
| Enumeration Date | 2006-07-19 |
| Last Update Date | 2012-09-14 |