| NPI | 1770109282 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: ID ODP-100565) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: AZ OPT-002440) |
| Enumeration Date | 2020-06-20 |
| Last Update Date | 2022-05-05 |