| NPI | 1073566253 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: FL OP0003250) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MD TA2900) |
| 152W00000X Optometrist (Licence: PA OEG003987) | |
| 152W00000X Optometrist (Licence: VA 0618003247) | |
| Enumeration Date | 2006-05-18 |
| Last Update Date | 2023-07-21 |