| NPI | 1104050483 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: UT 9490811-9934) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: NV 645) |
| 152W00000X Optometrist (Licence: PA OEG002297) | |
| Enumeration Date | 2009-05-14 |
| Last Update Date | 2021-02-24 |