| NPI | 1639178387 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: TX 0872) |
| Additional Taxonomies | 213EP1101X Podiatrist Primary Podiatric Medicine (Licence: TX PD872) |
| 213ES0103X Podiatrist Foot & Ankle Surgery (Licence: TX PD872) | |
| Enumeration Date | 2005-07-15 |
| Last Update Date | 2018-07-19 |