| NPI | 1124043724 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MO 2006001515) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: NC 1859) |
| 152WC0802X Optometrist, Corneal and Contact Management (Licence: MO 2006001515) | |
| Enumeration Date | 2006-07-13 |
| Last Update Date | 2024-03-05 |