| NPI | 1386620631 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207N00000X Dermatology (Licence: NY 114091-1) |
| Additional Taxonomies | 207N00000X Dermatology (Licence: FL ME132341) |
| Enumeration Date | 2005-12-19 |
| Last Update Date | 2021-04-27 |