| NPI | 1396740262 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: ID ODP-100002) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: AZ 295) |
| 152W00000X Optometrist (Licence: UT 114212-9934) | |
| Enumeration Date | 2005-06-16 |
| Last Update Date | 2023-05-08 |