| NPI | 1407944812 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: AZ OPT-002330) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OH 5223T2127) |
| Enumeration Date | 2006-10-11 |
| Last Update Date | 2022-11-16 |