| NPI | 1053521583 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: DE C1-0011566) |
| Additional Taxonomies | 207QA0401X Family Medicine, Addiction Medicine (Licence: TX P0920) |
| 207QA0401X Family Medicine, Addiction Medicine (Licence: DE C1-0011566) | |
| 261Q00000X Clinic/Center (Licence: PA MD438370) | |
| Enumeration Date | 2007-05-23 |
| Last Update Date | 2023-02-08 |