| NPI | 1124113162 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: SC 1935) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: AL R-339) |
| 152W00000X Optometrist (Licence: GA OPT003370) | |
| Enumeration Date | 2006-10-04 |
| Last Update Date | 2024-05-03 |