| NPI | 1548299464 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QP2300X Clinic/Center Primary Care (Licence: MI 4301089537) |
| Additional Taxonomies | 207R00000X Internal Medicine (Licence: MI 4301089537) |
| 207R00000X Internal Medicine (Licence: WV 19513) | |
| 208D00000X General Practice (Licence: MI 4301089537) | |
| Enumeration Date | 2006-07-02 |
| Last Update Date | 2023-02-02 |