| NPI | 1811997752 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: FL OPC3639) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MA 4348) |
| 152W00000X Optometrist (Licence: NC 2141) | |
| Enumeration Date | 2005-07-21 |
| Last Update Date | 2012-04-13 |