| NPI | 1790762524 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 152W00000X Optometrist (Licence: ID ODP-1028) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: UT 359678-9934) |
| Enumeration Date | 2005-12-22 |
| Last Update Date | 2023-09-06 |