| NPI | 1114040664 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: FL PO2738) |
| Additional Taxonomies | 213EP1101X Podiatrist Primary Podiatric Medicine (Licence: FL PO2738) |
| 213ER0200X Podiatrist Radiology (Licence: FL PO2738) | |
| 213ES0131X Podiatrist Foot Surgery (Licence: FL PO2738) | |
| 213ES0000X Podiatrist Sports Medicine (Licence: FL PO2738) | |
| 213ES0103X Podiatrist Foot & Ankle Surgery (Licence: FL PO2738) | |
| Enumeration Date | 2007-04-09 |
| Last Update Date | 2025-08-13 |