| NPI | 1619085800 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: WV 1030-OD) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OH 5581) |
| 152W00000X Optometrist (Licence: PA OEG001717) | |
| 152W00000X Optometrist (Licence: IN 18004325) | |
| Enumeration Date | 2006-08-28 |
| Last Update Date | 2023-08-31 |