| NPI | 1831539105 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 152W00000X Optometrist (Licence: FL OPC6627) | 
| Additional Taxonomies | 152W00000X Optometrist (Licence: MI 4901004774) | 
| 152W00000X Optometrist (Licence: GA OPT003146) | |
| Enumeration Date | 2013-07-01 | 
| Last Update Date | 2025-07-21 |