| NPI | 1629069653 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: CT 47449) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: OH 34005575L) |
| Enumeration Date | 2005-10-31 |
| Last Update Date | 2016-01-17 |