| NPI | 1396715819 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: GA 002839) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MD TA1367) |
| 152W00000X Optometrist (Licence: SC 1780) | |
| Enumeration Date | 2006-01-26 |
| Last Update Date | 2022-03-25 |