| NPI | 1720121700 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: UT 6029479-9934) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: CO co2478) |
| Enumeration Date | 2007-02-15 |
| Last Update Date | 2022-07-21 |