| NPI | 1710595368 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | Yes | 
| Primary Taxonomy | 152W00000X Optometrist (Licence: TX 10977T) | 
| Additional Taxonomies | 152W00000X Optometrist (Licence: CO OPT.0003968) | 
| 152W00000X Optometrist (Licence: IL 046011574) | |
| 152W00000X Optometrist (Licence: GA OPT003257) | |
| Enumeration Date | 2020-07-20 | 
| Last Update Date | 2025-08-18 |