| NPI | 1629067889 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: CT 000087) |
| Additional Taxonomies | 332B00000X Durable Medical Equipment & Medical Supplies (Licence: CT 000087) |
| Enumeration Date | 2005-10-19 |
| Last Update Date | 2012-03-20 |