| NPI | 1043280555 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: UT 8897506) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: ID ODP-100087) |
| 152W00000X Optometrist (Licence: AK 235042) | |
| Enumeration Date | 2006-01-25 |
| Last Update Date | 2025-04-22 |