| NPI | 1487641825 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: NC 2454) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: TX 5803TG) |
| 152W00000X Optometrist (Licence: NM 590) | |
| 152W00000X Optometrist (Licence: SC 1870) | |
| Enumeration Date | 2005-09-30 |
| Last Update Date | 2024-01-29 |