| NPI | 1164562682 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: CT 3231) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: PA 0EG001877) |
| 152W00000X Optometrist (Licence: NY 007216) | |
| 152W00000X Optometrist (Licence: SC 1812) | |
| Enumeration Date | 2007-02-07 |
| Last Update Date | 2022-08-31 |