| NPI | 1053608950 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NY 278697) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: OH 278697) |
| Enumeration Date | 2011-06-30 |
| Last Update Date | 2022-11-03 |