| NPI | 1457470593 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: MA 232987) |
| Additional Taxonomies | 208D00000X General Practice (Licence: VT 42-0010768) |
| 208D00000X General Practice (Licence: NY 154574-1) | |
| Enumeration Date | 2007-03-28 |
| Last Update Date | 2008-09-30 |