| NPI | 1104912773 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QA0505X Family Medicine, Adult Medicine (Licence: OH 35074317s) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: OH 35074317s) |
| Enumeration Date | 2006-10-04 |
| Last Update Date | 2013-05-02 |