| NPI | 1114650017 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MD TA2856) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: VA 0618003130) |
| Enumeration Date | 2022-07-07 |
| Last Update Date | 2022-07-07 |