| NPI | 1932464013 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: GA OPT002804) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: VA 0618002161) |
| Enumeration Date | 2012-07-05 |
| Last Update Date | 2016-03-01 |