| NPI | 1104117514 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2085R0202X Radiology, Diagnostic Radiology (Licence: PA MD462812) |
| Additional Taxonomies | 2085R0202X Radiology, Diagnostic Radiology (Licence: CT 055216) |
| Enumeration Date | 2011-04-20 |
| Last Update Date | 2020-05-04 |