| NPI | 1902817158 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207W00000X Ophthalmology (Licence: CA G19795) |
| Additional Taxonomies | 332H00000X Eyewear Supplier (Licence: CA 0788400001) |
| Enumeration Date | 2006-08-11 |
| Last Update Date | 2007-11-09 |