| NPI | 1053781013 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WA OD60963772) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: TX 8767TG) |
| 152W00000X Optometrist (Licence: FL OPC5620) | |
| Enumeration Date | 2015-10-03 |
| Last Update Date | 2019-08-29 |