| NPI | 1033128145 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: FL OPC5988) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MA 4238) |
| 152W00000X Optometrist (Licence: OH OPT.006835) | |
| 152W00000X Optometrist (Licence: AK OD5494) | |
| Enumeration Date | 2006-08-07 |
| Last Update Date | 2023-07-18 |