| NPI | 1396857017 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: OH 36-00-3213 S) |
| Additional Taxonomies | 213EP1101X Podiatrist, Primary Podiatric Medicine (Licence: WV 10405) |
| Enumeration Date | 2006-08-31 |
| Last Update Date | 2010-11-13 |