| NPI | 1174257869 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: CT 3273) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: VA 0618003565) |
| Enumeration Date | 2022-07-11 |
| Last Update Date | 2025-10-22 |