| NPI | 1629101928 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207QA0401X Family Medicine Addiction Medicine (Licence: ID O-163) |
| Additional Taxonomies | 207VE0102X Obstetrics & Gynecology Reproductive Endocrinology (Licence: ID O-163) |
| 208D00000X General Practice (Licence: ID 0-163) | |
| Enumeration Date | 2007-03-14 |
| Last Update Date | 2012-02-06 |