| NPI | 1396887196 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261Q00000X Clinic/Center |
| Additional Taxonomies | 208000000X Pediatrics (Licence: PR 06795) |
| 208D00000X General Practice (Licence: PR 06795) | |
| Enumeration Date | 2007-02-12 |
| Last Update Date | 2015-12-30 |