| NPI | 1720565641 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MD TA3006) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: PA OEG003439) |
| 152W00000X Optometrist (Licence: DE I3-0001417) | |
| Enumeration Date | 2018-07-24 |
| Last Update Date | 2024-06-27 |