| NPI | 1083616007 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: TX J7090) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: FL ME 74872) |
| 208000000X Pediatrics (Licence: PA MD-052944-L) | |
| 208000000X Pediatrics (Licence: PR 011583) | |
| Enumeration Date | 2005-08-10 |
| Last Update Date | 2015-11-09 |