| NPI | 1891765830 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: VA 0618000268) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: PA OE005807P) |
| Enumeration Date | 2006-01-24 |
| Last Update Date | 2007-07-16 |