| NPI | 1619594470 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MO 2020015615) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: IL 046.011449) |
| 152WX0102X Optometrist Occupational Vision (Licence: MO 2020015615) | |
| Enumeration Date | 2020-06-28 |
| Last Update Date | 2022-06-10 |