| NPI | 1609354695 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: NC 2632) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: SC 2556) |
| 152W00000X Optometrist (Licence: NY 008798) | |
| Enumeration Date | 2018-08-01 |
| Last Update Date | 2025-08-25 |