| NPI | 1144219213 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: SD SD491) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MN 2118) |
| Enumeration Date | 2005-10-20 |
| Last Update Date | 2023-03-07 |