| NPI | 1972536175 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: FL OPC2300) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MA 3449) |
| 152W00000X Optometrist (Licence: TX 6683T) | |
| 152W00000X Optometrist (Licence: WI 2666-035) | |
| Enumeration Date | 2006-07-09 |
| Last Update Date | 2011-05-10 |