| NPI | 1831203884 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WV 703OD) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: PA OEG001175) |
| Enumeration Date | 2006-08-18 |
| Last Update Date | 2016-11-14 |