| NPI | 1629630439 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: AZ OPT-002634) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: VA 0618002875) |
| 152W00000X Optometrist (Licence: OH OPT.006804) | |
| Enumeration Date | 2019-07-01 |
| Last Update Date | 2023-01-29 |