| NPI | 1710503412 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: KS 2117) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: AZ OPT-002433) |
| Enumeration Date | 2020-06-18 |
| Last Update Date | 2020-07-14 |