| NPI | 1386955565 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: TX 7686T) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: FL OPC5006) |
| 152W00000X Optometrist (Licence: VA 0618001953) | |
| Enumeration Date | 2010-06-23 |
| Last Update Date | 2022-10-23 |