| NPI | 1235578568 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: AZ 2567) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: TX 8222-T) |
| Enumeration Date | 2013-06-19 |
| Last Update Date | 2025-06-28 |