| NPI | 1013950104 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: FL ME77125) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: NY 212728) |
| Enumeration Date | 2006-06-14 |
| Last Update Date | 2013-10-08 |