| NPI | 1104152487 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: TX P3474) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: OH 57.016708) |
| Enumeration Date | 2009-10-21 |
| Last Update Date | 2022-08-30 |