| NPI | 1255687554 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: NC 2319) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: VA 0618002173) |
| Enumeration Date | 2012-07-24 |
| Last Update Date | 2023-05-22 |