| NPI | 1629066816 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: VA 0103000771) |
| Additional Taxonomies | 213E00000X Podiatrist (Licence: OH 36002143) |
| Enumeration Date | 2005-10-11 |
| Last Update Date | 2010-07-02 |