| NPI | 1073513412 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: KY 2463DT) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: PA OEG001266) |
| Enumeration Date | 2005-07-28 |
| Last Update Date | 2025-12-05 |