| NPI | 1104057363 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: TX 7818TG) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: TX 7818-T) |
| 152W00000X Optometrist (Licence: VA 0618001882) | |
| Enumeration Date | 2009-08-05 |
| Last Update Date | 2020-07-30 |