| NPI | 1104012715 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2085R0202X Radiology Diagnostic Radiology (Licence: FL ME110484) |
| Additional Taxonomies | 2085P0229X Radiology Pediatric Radiology (Licence: MA 243722) |
| Enumeration Date | 2007-09-18 |
| Last Update Date | 2011-07-20 |