| NPI | 1669813721 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MO 2015003345) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: PA OEG002829) |
| Enumeration Date | 2013-07-17 |
| Last Update Date | 2023-06-23 |