| NPI | 1104980846 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: AZ 1127) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: WI 21201-875) |
| 207W00000X Ophthalmology (Licence: MD TA1769) | |
| Enumeration Date | 2006-12-20 |
| Last Update Date | 2022-03-22 |