| NPI | 1912030750 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: NV 916) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: NJ 27OA00511100) |
| 152W00000X Optometrist (Licence: NY TUV005156) | |
| Enumeration Date | 2007-03-13 |
| Last Update Date | 2021-12-12 |