| NPI | 1154364842 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: VA 0618000929) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MD TA2335) |
| 152W00000X Optometrist (Licence: PA OEG002741) | |
| Enumeration Date | 2006-06-13 |
| Last Update Date | 2022-04-21 |