| NPI | 1073507125 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: NC 1006) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: SC 652) |
| 152W00000X Optometrist (Licence: FL OP1475) | |
| Enumeration Date | 2005-09-06 |
| Last Update Date | 2024-04-09 |