| NPI | 1710595368 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: TX 10977) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: IL 046011574) |
| 152W00000X Optometrist (Licence: CO OPT.0003968) | |
| 152W00000X Optometrist (Licence: GA OPT003257) | |
| Enumeration Date | 2020-07-20 |
| Last Update Date | 2026-10-01 |