| NPI | 1053764803 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: TN 3296) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OH 007017) |
| 152WS0006X Optometrist Sports Vision (Licence: TN 3296) | |
| 152WV0400X Optometrist Vision Therapy (Licence: TN 3296) | |
| Enumeration Date | 2016-07-18 |
| Last Update Date | 2022-04-19 |