| NPI | 1548613391 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: KY 2023DT) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OH 6441) |
| Enumeration Date | 2016-07-18 |
| Last Update Date | 2025-09-05 |