| NPI | 1255321485 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: MI 5901000539) |
| Additional Taxonomies | 213E00000X Podiatrist (Licence: MI 360102) |
| Enumeration Date | 2005-10-27 |
| Last Update Date | 2008-07-18 |