| NPI | 1063890200 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: OH 35.133539) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: SC LL38060) |
| Enumeration Date | 2015-05-08 |
| Last Update Date | 2020-10-26 |