| NPI | 1306191978 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MD TA2615) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: TX 8314-TG) |
| 152W00000X Optometrist (Licence: PA OEG002675) | |
| Enumeration Date | 2012-07-19 |
| Last Update Date | 2019-05-13 |