| NPI | 1679887756 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: ID ODP-100580) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: UT 7719282-9934) |
| Enumeration Date | 2010-08-02 |
| Last Update Date | 2023-06-22 |