| NPI | 1174870422 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MO 2012025341) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: CO 0002930) |
| Enumeration Date | 2012-08-06 |
| Last Update Date | 2025-04-29 |