| NPI | 1104182989 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2085R0001X (Licence: WI 4556-850) |
| Additional Taxonomies | 207R00000X Internal Medicine (Licence: IL 125061671) |
| Enumeration Date | 2012-04-06 |
| Last Update Date | 2017-07-03 |