| NPI | 1790798189 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WI 324235) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: IL 046.009440) |
| 152W00000X Optometrist (Licence: IN 18003173) | |
| Enumeration Date | 2006-08-15 |
| Last Update Date | 2011-12-21 |