| NPI | 1558732412 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: OH OPT.6426) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: VA 0618002460) |
| 152W00000X Optometrist (Licence: WV 2020-IOD1) | |
| Enumeration Date | 2015-10-16 |
| Last Update Date | 2016-07-07 |