| NPI | 1720216583 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: NE 1318) |
| Additional Taxonomies | 152WP0200X Optometrist Pediatrics (Licence: NE 1318) |
| 152WS0006X Optometrist Sports Vision (Licence: NE 1318) | |
| 152WV0400X Optometrist Vision Therapy (Licence: NE 1318) | |
| Enumeration Date | 2009-06-30 |
| Last Update Date | 2019-07-09 |