| NPI | 1417940883 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: OH 35034307) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: OH 35034307) |
| Enumeration Date | 2005-08-31 |
| Last Update Date | 2012-01-20 |