| NPI | 1124142054 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL me104439) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: OH 57.011962) |
| Enumeration Date | 2007-03-17 |
| Last Update Date | 2018-01-30 |