| NPI | 1730129537 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MO 2006006993) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: KY 2042DT) |
| Enumeration Date | 2006-06-08 |
| Last Update Date | 2023-02-23 |