| NPI | 1598759250 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: KY 1241DT) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: KY 1241-DT) |
| 152WP0200X Optometrist Pediatrics (Licence: KY 1241DT) | |
| Enumeration Date | 2005-09-08 |
| Last Update Date | 2022-08-16 |