| NPI | 1194565903 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: CT 3350) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: NY 009990) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2024-05-29 |
| Last Update Date | 2024-07-22 |