| NPI | 1164546313 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: CA 12174) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: AK 286) |
| 174400000X Specialist (Licence: MD DA2093) | |
| 174400000X Specialist (Licence: VA 0618001782) | |
| Enumeration Date | 2007-03-16 |
| Last Update Date | 2021-07-27 |