| NPI | 1063462778 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: UT 11993238-9934) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: KY 2028DT) |
| 152W00000X Optometrist (Licence: CA OPT 12423 TPA) | |
| Enumeration Date | 2006-05-11 |
| Last Update Date | 2024-12-03 |