| NPI | 1568557940 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: AZ OPT-001878) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: GA 001139) |
| 152W00000X Optometrist (Licence: UT 6249139-9934) | |
| 152W00000X Optometrist (Licence: FL 0002237) | |
| Enumeration Date | 2006-10-03 |
| Last Update Date | 2020-12-02 |