| NPI | 1134280480 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QM2500X Clinic/Center, Medical Specialty (Licence: NJ 25MA04163600) |
| Additional Taxonomies | 261QP2400X Clinic/Center, Prison Health (Licence: NJ MA2504163600) |
| Enumeration Date | 2006-12-12 |
| Last Update Date | 2007-07-08 |