| NPI | 1548512882 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: ID 9271590) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OK 2868) |
| Enumeration Date | 2012-10-10 |
| Last Update Date | 2026-06-18 |