| NPI | 1568636629 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: MI 4301095806) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 4301095806) |
| 207Q00000X Family Medicine (Licence: IL 125052101) | |
| Enumeration Date | 2008-04-18 |
| Last Update Date | 2025-12-16 |