| NPI | 1679908669 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: AZ OPT-002157) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: SC 1753) |
| Enumeration Date | 2013-09-09 |
| Last Update Date | 2022-10-12 |