| NPI | 1730158080 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: VA 0618002914) |
| Additional Taxonomies | 174400000X Specialist (Licence: OH 4188 T45) |
| Enumeration Date | 2006-03-17 |
| Last Update Date | 2023-10-06 |