| NPI | 1104156488 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: NJ 25ma07662800) |
| Additional Taxonomies | 208D00000X General Practice (Licence: NY 328118) |
| 208D00000X General Practice (Licence: FL ME169225) | |
| 208D00000X General Practice (Licence: OK 43785) | |
| 208D00000X General Practice (Licence: ND 21369) | |
| Enumeration Date | 2010-01-08 |
| Last Update Date | 2025-10-13 |