| NPI | 1205454055 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MD TA2789) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: PA OEG003676) |
| Enumeration Date | 2020-07-08 |
| Last Update Date | 2022-04-11 |