| NPI | 1962943399 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 152W00000X Optometrist (Licence: MO 2024013145) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: IL 046.011255) |
| Enumeration Date | 2017-03-18 |
| Last Update Date | 2024-07-25 |