| NPI | 1790064947 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WI 3437-35) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MI 4901004654) |
| Enumeration Date | 2011-08-05 |
| Last Update Date | 2020-12-08 |