| NPI | 1558682567 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 207R00000X Internal Medicine (Licence: OH 35.120488) | 
| Additional Taxonomies | 207R00000X Internal Medicine (Licence: LA 305505) | 
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2010-06-14 | 
| Last Update Date | 2019-09-11 |