| NPI | 1104072941 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: VA 0618002028) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: CO OPT0003622) |
| 152W00000X Optometrist (Licence: WI 3733-35) | |
| 152W00000X Optometrist (Licence: FL TPOP13) | |
| 152W00000X Optometrist (Licence: MD TA2960) | |
| Enumeration Date | 2008-08-12 |
| Last Update Date | 2024-02-20 |