| NPI | 1790039030 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MA OPT8244) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: PA OEG002632) |
| Enumeration Date | 2012-11-08 |
| Last Update Date | 2025-09-10 |