| NPI | 1063289916 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MO 2024035315) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MD TA2972) |
| Enumeration Date | 2023-12-11 |
| Last Update Date | 2024-09-18 |