| NPI | 1124436464 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MN 3360) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: FL OPC4881) |
| 152W00000X Optometrist (Licence: AZ OPT-002475) | |
| Enumeration Date | 2014-07-31 |
| Last Update Date | 2021-02-24 |