| NPI | 1528415148 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: TX 9043TG) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: UT 9809857-9934) |
| Enumeration Date | 2016-05-24 |
| Last Update Date | 2023-01-20 |