| NPI | 1083606974 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 213E00000X Podiatrist (Licence: OH 36003149) | 
| Additional Taxonomies | 213E00000X Podiatrist (Licence: KY 00258) | 
| 213E00000X Podiatrist (Licence: KY 244160) | |
| Enumeration Date | 2005-08-17 | 
| Last Update Date | 2024-05-07 |