| NPI | 1609514306 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MI 4901005772) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OH OPT.007036) |
| Enumeration Date | 2022-05-23 |
| Last Update Date | 2025-01-17 |