| NPI | 1164415915 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: NY N002653) |
| Additional Taxonomies | 183500000X Pharmacist (Licence: NY 027828-1) |
| Enumeration Date | 2005-08-26 |
| Last Update Date | 2010-03-01 |