| NPI | 1235403742 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: NY 000-26-4414) |
| Additional Taxonomies | 208600000X Surgery (Licence: NY 264414) |
| 207Q00000X Family Medicine (Licence: NY 264414) | |
| Enumeration Date | 2012-03-01 |
| Last Update Date | 2026-03-13 |