| NPI | 1104488634 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: DE I3-0001427) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: PA OEG003540) |
| Enumeration Date | 2019-07-04 |
| Last Update Date | 2020-10-18 |