| NPI | 1568807584 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | Yes | 
| Primary Taxonomy | 207R00000X Internal Medicine (Licence: GU M2066)  | 
| Additional Taxonomies | 207R00000X Internal Medicine (Licence: PR 019743)  | 
| Enumeration Date | 2013-05-03 | 
| Last Update Date | 2018-11-14 |