| NPI | 1730120114 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MD TA947) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: VA 618000559) |
| Enumeration Date | 2006-06-09 |
| Last Update Date | 2021-10-13 |