| NPI | 1790048403 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: NE 1377) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: IA 002611) |
| Enumeration Date | 2012-06-18 |
| Last Update Date | 2021-09-09 |