| NPI | 1578774568 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MI 4301093314) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: OH 57012042) |
| Enumeration Date | 2007-05-24 |
| Last Update Date | 2012-09-20 |