| NPI | 1861922601 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: AZ OPT-002328) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: ID ODP-100409) |
| Enumeration Date | 2017-06-14 |
| Last Update Date | 2021-11-02 |