| NPI | 1093172918 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207N00000X Dermatology (Licence: MA 266239) |
| Additional Taxonomies | 261QV0200X Clinic/Center, VA (Licence: MA 266236) |
| Enumeration Date | 2016-01-22 |
| Last Update Date | 2017-04-01 |