| NPI | 1104960129 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: VA 0618000752) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MD TA1514) |
| 152W00000X Optometrist (Licence: WV 2023-OD) | |
| Enumeration Date | 2007-02-16 |
| Last Update Date | 2025-09-17 |