| NPI | 1639697584 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MD TA2605) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: FL OPC5478) |
| Enumeration Date | 2017-08-30 |
| Last Update Date | 2022-07-21 |