| NPI | 1972614923 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MD TA1880) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: VA 0618001380) |
| 152W00000X Optometrist (Licence: TX T3196) | |
| Enumeration Date | 2006-08-31 |
| Last Update Date | 2007-07-08 |