| NPI | 1508550898 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: UT 14217854-9934) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: ID ODP-100624) |
| Enumeration Date | 2023-06-08 |
| Last Update Date | 2026-07-31 |