| NPI | 1972988525 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 152W00000X Optometrist (Licence: AZ OPT-002306) |
| Additional Taxonomies | 152W00000X Optometrist (Licence: NY TUV008345) |
| Enumeration Date | 2015-07-24 |
| Last Update Date | 2019-05-30 |