| NPI | 1407864093 |
|---|---|
| Doing Business As | |
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WI 48314) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: IL 036-113334) |
| Enumeration Date | 2006-08-03 |
| Last Update Date | 2023-10-18 |