| NPI | 1619289873 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: TX 7577) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: SC 2614) |
| Enumeration Date | 2010-07-05 |
| Last Update Date | 2026-07-08 |