| NPI | 1811072036 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MD TA1028) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: VA 0618000560) |
| 152W00000X Optometrist (Licence: PA OE007042P) | |
| Enumeration Date | 2006-10-26 |
| Last Update Date | 2018-01-30 |