| NPI | 1053363341 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207N00000X Dermatology (Licence: MD D0061664) |
| Additional Taxonomies | 332900000X Non-Pharmacy Dispensing Site |
| Enumeration Date | 2006-05-16 |
| Last Update Date | 2019-05-24 |