| NPI | 1689055931 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MT OPT-OPT-LIC-4926) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: MN 3435) |
| 152W00000X Optometrist (Licence: WI 3395) | |
| Enumeration Date | 2015-06-12 |
| Last Update Date | 2025-12-19 |