| NPI | 1902880057 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: IL 046-009714) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: KY 1553DT) |
| Enumeration Date | 2005-12-02 |
| Last Update Date | 2012-09-17 |