| NPI | 1083768295 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QM2500X Clinic/Center, Medical Specialty (Licence: CA C27180) |
| Additional Taxonomies | 207N00000X Dermatology (Licence: CA C27180) |
| Enumeration Date | 2007-01-23 |
| Last Update Date | 2010-03-30 |