| NPI | 1265173041 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207W00000X Ophthalmology (Licence: VA 0101280358) |
| Additional Taxonomies | 208D00000X General Practice (Licence: VA 0101280358) |
| 171000000X Military Health Care Provider | |
| Enumeration Date | 2022-04-05 |
| Last Update Date | 2026-08-10 |