| NPI | 1770575946 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152WP0200X Optometrist, Pediatrics (Licence: MD DA2217) |
| Additional Taxonomies | 152WP0200X Optometrist, Pediatrics (Licence: PR 417) |
| 152WP0200X Optometrist, Pediatrics (Licence: MI 4901004515) | |
| Enumeration Date | 2005-08-16 |
| Last Update Date | 2013-07-19 |