| NPI | 1083962245 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: UT 5596291-9934) |
| Additional Taxonomies | 207W00000X Ophthalmology (Licence: UT 5596291-9934) |
| Enumeration Date | 2012-08-20 |
| Last Update Date | 2021-05-19 |