| NPI | 1902836547 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: TX 07022TG) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: PA OEG001524) |
| Enumeration Date | 2006-07-03 |
| Last Update Date | 2010-02-24 |