| NPI | 1902860323 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: SC 1333) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OH 3329/T179) |
| Enumeration Date | 2006-04-13 |
| Last Update Date | 2007-10-11 |