| NPI | 1609873942 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: TN OD0000001640) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: GA OPT002084) |
| Enumeration Date | 2005-07-01 |
| Last Update Date | 2023-03-07 |