| NPI | 1578796983 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MI 4301086718) |
| Additional Taxonomies | 208D00000X General Practice (Licence: NY 234731) |
| Enumeration Date | 2009-09-01 |
| Last Update Date | 2009-12-11 |