| NPI | 1104818954 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: PR 9201) |
| Additional Taxonomies | 208D00000X General Practice (Licence: PR 9201) |
| Enumeration Date | 2005-08-18 |
| Last Update Date | 2020-11-10 |