| NPI | 1871558320 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: OH 4269-T046) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: WV 954-OD) |
| Enumeration Date | 2006-04-19 |
| Last Update Date | 2008-06-10 |