| NPI | 1386704682 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2080A0000X Pediatrics Adolescent Medicine (Licence: CT 025919) |
| Additional Taxonomies | 2080A0000X Pediatrics Adolescent Medicine (Licence: NY 162232) |
| Enumeration Date | 2006-12-11 |
| Last Update Date | 2007-07-08 |