| NPI | 1689779712 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: PA OEG003775) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: OH 4248T125) |
| 152W00000X Optometrist (Licence: MO T02793) | |
| 152W00000X Optometrist (Licence: OR 2042) | |
| Enumeration Date | 2006-09-13 |
| Last Update Date | 2025-05-22 |