| NPI | 1992017123 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: GA 2621) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: SC 1601) |
| Enumeration Date | 2010-07-02 |
| Last Update Date | 2012-03-29 |