| NPI | 1275225377 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WA OD61602126) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OH OPT.007166) |
| Enumeration Date | 2023-05-25 |
| Last Update Date | 2025-06-19 |