| NPI | 1124048848 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: MI 4301054826) |
| Additional Taxonomies | 261QP2300X Clinic/Center, Primary Care (Licence: MI 4301054826) |
| Enumeration Date | 2006-07-19 |
| Last Update Date | 2019-06-10 |