| NPI | 1104133917 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: FL ME111301) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: NY 098719) |
| Enumeration Date | 2010-09-01 |
| Last Update Date | 2014-08-28 |