| NPI | 1912938143 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: NY VUT005758) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MO 2004033422) |
| Enumeration Date | 2006-07-05 |
| Last Update Date | 2007-07-08 |