| NPI | 1902312143 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: NY 009422) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: LA 2081-028AT) |
| 152W00000X Optometrist (Licence: PA OEG004382) | |
| Enumeration Date | 2017-12-26 |
| Last Update Date | 2026-07-29 |