| NPI | 1407872500 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: IL 036-073808) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: IA 3350) |
| 207Q00000X Family Medicine (Licence: WI 42827-021) | |
| 207Q00000X Family Medicine (Licence: MN 43369) | |
| Enumeration Date | 2006-07-14 |
| Last Update Date | 2008-04-15 |