| NPI | 1114120748 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208100000X Physical Medicine & Rehabilitation (Licence: FL ME99545) |
| Additional Taxonomies | 2081S0010X Physical Medicine & Rehabilitation, Sports Medicine (Licence: NJ 25MA08112700) |
| Enumeration Date | 2007-06-10 |
| Last Update Date | 2026-07-06 |