| NPI | 1114282258 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MO 2016039155) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: AZ 1911) |
| 152W00000X Optometrist (Licence: ID ODP-100253) | |
| 152W00000X Optometrist (Licence: TN OD0000003234) | |
| 152W00000X Optometrist (Licence: WA OD 60299099) | |
| Enumeration Date | 2012-07-04 |
| Last Update Date | 2022-07-21 |