| NPI | 1164427969 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: RI ODTG00763) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: LA 1390521T) |
| 152W00000X Optometrist (Licence: NY TUV008866) | |
| 152W00000X Optometrist (Licence: MA OPT7131) | |
| Enumeration Date | 2005-06-17 |
| Last Update Date | 2025-07-23 |