| NPI | 1932445202 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: GA OPT003070) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: VA 0618002199) |
| 152W00000X Optometrist (Licence: MD TA2384) | |
| Enumeration Date | 2012-12-14 |
| Last Update Date | 2019-05-02 |