| NPI | 1780683698 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: SC 1408) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: NE 1244) |
| 152W00000X Optometrist (Licence: NC 2086) | |
| Enumeration Date | 2005-07-21 |
| Last Update Date | 2018-03-01 |