| NPI | 1902983604 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: CO OPT-2705) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: UT 5350509-9934) |
| Enumeration Date | 2006-11-01 |
| Last Update Date | 2009-09-25 |