| NPI | 1063535664 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207R00000X Internal Medicine (Licence: NJ 25MA08345000) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: PA MT 183518) |
| Enumeration Date | 2007-04-09 |
| Last Update Date | 2024-01-16 |