| NPI | 1982612800 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: VA 0618001815) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: GA OPT002305) |
| Enumeration Date | 2006-08-04 |
| Last Update Date | 2009-01-05 |