| NPI | 1811059421 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 152W00000X Optometrist (Licence: DC OP744)  | 
| Additional Taxonomies | 152W00000X Optometrist (Licence: MD TA1334)  | 
| Enumeration Date | 2006-12-14 | 
| Last Update Date | 2011-12-23 |