| NPI | 1104368216 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: OR AT4482) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: SC 1955) |
| Enumeration Date | 2016-11-07 |
| Last Update Date | 2026-04-10 |