| NPI | 1205569563 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: VA 0618003240) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: KY 2290DT) |
| Enumeration Date | 2022-07-05 |
| Last Update Date | 2024-10-14 |