| NPI | 1962681171 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: AK 329) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: TX 7105T) |
| 152W00000X Optometrist (Licence: WA OD00004141) | |
| Enumeration Date | 2007-10-24 |
| Last Update Date | 2013-12-11 |