| NPI | 1053392696 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: TX 11397) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: NY VUT006400) |
| 152W00000X Optometrist (Licence: CA 12180TLG) | |
| Enumeration Date | 2005-11-10 |
| Last Update Date | 2025-12-08 |