| NPI | 1457337784 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: MI MB001342) |
| Additional Taxonomies | 213ES0103X Podiatrist, Foot & Ankle Surgery (Licence: MI MB001342) |
| Enumeration Date | 2005-12-19 |
| Last Update Date | 2011-04-13 |