| NPI | 1770063687 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: DE I3-0011449) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: PA OEG003474) |
| Enumeration Date | 2018-08-20 |
| Last Update Date | 2022-07-28 |