| NPI | 1063413854 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: CT 028872) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: NY 163113) |
| Enumeration Date | 2005-08-03 |
| Last Update Date | 2014-04-11 |