| NPI | 1912104985 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: NJ 27OA00624200) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: PA OEG001902) |
| 152W00000X Optometrist (Licence: FL OPC4494) | |
| 152W00000X Optometrist (Licence: NY TUV007515) | |
| Enumeration Date | 2007-07-02 |
| Last Update Date | 2014-11-13 |