| NPI | 1720577638 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: PA OEG003761) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: VT 030.0133926) |
| 152WP0200X Optometrist, Pediatrics (Licence: GA 1234) | |
| Enumeration Date | 2018-05-07 |
| Last Update Date | 2021-07-13 |