| NPI | 1114928074 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213EP1101X Podiatrist Primary Podiatric Medicine (Licence: CT 395) |
| Additional Taxonomies | 213ES0000X Podiatrist Sports Medicine (Licence: CT 395) |
| 213ES0131X Podiatrist Foot Surgery (Licence: CT 395) | |
| 332B00000X Durable Medical Equipment & Medical Supplies (Licence: CT 395) | |
| Enumeration Date | 2005-08-02 |
| Last Update Date | 2011-11-14 |