| NPI | 1578978201 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MD TA2485) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: PA OEG002929) |
| Enumeration Date | 2014-06-20 |
| Last Update Date | 2023-05-10 |