| NPI | 1861562217 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MA MA 2567T) |
| Additional Taxonomies | 152WP0200X Optometrist Pediatrics (Licence: MA MA 2567T) |
| 152WV0400X Optometrist Vision Therapy (Licence: MA MA 2567T) | |
| 152WS0006X Optometrist Sports Vision (Licence: MA MA 2567T) | |
| Enumeration Date | 2006-11-09 |
| Last Update Date | 2022-03-02 |