| NPI | 1588005607 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: AZ 1907) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: UT 8683123-9934) |
| Enumeration Date | 2013-07-17 |
| Last Update Date | 2021-06-07 |