| NPI | 1083611784 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: MI 5901000677) |
| Additional Taxonomies | 213E00000X Podiatrist (Licence: NV 0207) |
| Enumeration Date | 2005-07-07 |
| Last Update Date | 2008-09-30 |