| NPI | 1013204890 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: NE 1380) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: IA 002558) |
| Enumeration Date | 2011-06-30 |
| Last Update Date | 2026-04-22 |