| NPI | 1174504690 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: FL ME122911) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: NY 168071) |
| Enumeration Date | 2005-11-10 |
| Last Update Date | 2021-08-18 |