| NPI | 1205091410 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: TX 1988) |
| Additional Taxonomies | 213ES0103X Podiatrist Foot & Ankle Surgery (Licence: MO 2008018676) |
| Enumeration Date | 2008-07-28 |
| Last Update Date | 2019-09-27 |