| NPI | 1104381573 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207W00000X Ophthalmology (Licence: VA 0102208301) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2019-02-09 |
| Last Update Date | 2026-08-21 |