| NPI | 1760472369 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: AZ OPT-001424) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: CO OPT.0001515) |
| Enumeration Date | 2005-10-25 |
| Last Update Date | 2025-10-29 |