| NPI | 1710479001 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: UT 11277045-9934) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: TN 3443) |
| Enumeration Date | 2018-06-01 |
| Last Update Date | 2019-06-03 |