| NPI | 1538784772 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: GA OPT003399) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OH OPT.006886) |
| Enumeration Date | 2020-06-13 |
| Last Update Date | 2022-04-22 |