| NPI | 1235303801 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: NY 173465) |
| Additional Taxonomies | 208D00000X General Practice (Licence: MT 11857) |
| Enumeration Date | 2008-04-15 |
| Last Update Date | 2012-01-30 |