| NPI | 1811993694 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MA 2778) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: VT 030.0133967) |
| 152W00000X Optometrist (Licence: RI ODTA00559) | |
| 152W00000X Optometrist (Licence: WI 3867-35) | |
| 152W00000X Optometrist (Licence: FL TPOP103) | |
| Enumeration Date | 2005-06-25 |
| Last Update Date | 2023-02-17 |