| NPI | 1790347904 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MD TA2670) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: VA 0618002764) |
| Enumeration Date | 2019-07-08 |
| Last Update Date | 2020-07-10 |