| NPI | 1174367197 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: OH OPT.007402) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MO 2024020286) |
| Enumeration Date | 2024-06-24 |
| Last Update Date | 2025-12-04 |