| NPI | 1124047121 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: NY 215826) |
| Additional Taxonomies | 208D00000X General Practice (Licence: NY 215826) |
| Enumeration Date | 2006-07-19 |
| Last Update Date | 2017-05-04 |