| NPI | 1114070570 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207RG0300X Internal Medicine Geriatric Medicine (Licence: PR 15837) |
| Additional Taxonomies | 261QV0200X Clinic/Center VA (Licence: FL ME114422) |
| Enumeration Date | 2007-01-19 |
| Last Update Date | 2017-01-09 |