| NPI | 1073792123 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: GA OPT003212) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: CO OPT.0003471) |
| 152W00000X Optometrist (Licence: TX 05888TG) | |
| Enumeration Date | 2007-10-25 |
| Last Update Date | 2020-08-21 |