| NPI | 1639646664 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MN 3655) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: NJ 27OA00684100) |
| Enumeration Date | 2018-10-29 |
| Last Update Date | 2019-09-23 |