| NPI | 1811900756 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: LA 1276-434T) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: AZ 1063-495t) |
| Enumeration Date | 2006-08-14 |
| Last Update Date | 2010-12-06 |