| NPI | 1962542670 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: AZ p659a) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: AZ 1343) |
| 152W00000X Optometrist (Licence: CA 12497tpa) | |
| Enumeration Date | 2007-02-08 |
| Last Update Date | 2014-01-31 |