| NPI | 1902213804 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WV 2009-IOD1) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: VA 0618002334) |
| Enumeration Date | 2014-07-13 |
| Last Update Date | 2015-09-28 |