| NPI | 1184886111 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213ES0103X Podiatrist, Foot & Ankle Surgery (Licence: MI 5901002313) |
| Additional Taxonomies | 213E00000X Podiatrist (Licence: MI 5901002313) |
| 213E00000X Podiatrist (Licence: ME POD1063) | |
| 332900000X Non-Pharmacy Dispensing Site | |
| Enumeration Date | 2008-07-01 |
| Last Update Date | 2023-10-23 |