| NPI | 1972605905 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: RI ODTG00480) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MA 2550) |
| Enumeration Date | 2006-09-01 |
| Last Update Date | 2012-08-01 |