| NPI | 1801889530 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: DC OP1000121) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: VA 0618000479) |
| Enumeration Date | 2005-08-29 |
| Last Update Date | 2021-12-13 |