| NPI | 1639289259 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213EP1101X Podiatrist, Primary Podiatric Medicine (Licence: CT CT404) |
| Additional Taxonomies | 213E00000X Podiatrist (Licence: CT CT404) |
| 213ES0103X Podiatrist, Foot & Ankle Surgery (Licence: CT CT404) | |
| Enumeration Date | 2006-08-30 |
| Last Update Date | 2009-11-05 |