| NPI | 1770547960 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: OH 5471 T2383) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: AK 237) |
| 152WS0006X Optometrist, Sports Vision (Licence: OH 5471 T2383) | |
| Enumeration Date | 2006-04-14 |
| Last Update Date | 2013-06-18 |