| NPI | 1073512448 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: IA 06600) |
| Additional Taxonomies | 213E00000X Podiatrist (Licence: IL 016-005138) |
| Enumeration Date | 2005-07-19 |
| Last Update Date | 2021-11-05 |