| NPI | 1235366931 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: FL OPC4977) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: NC 2153) |
| 152W00000X Optometrist (Licence: VA 0618001842) | |
| Enumeration Date | 2009-06-19 |
| Last Update Date | 2021-06-03 |