| NPI | 1669471462 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: OH 35-06-0566M) |
| Additional Taxonomies | 174400000X Specialist (Licence: PA MD048666L) |
| 208D00000X General Practice (Licence: CT 049834) | |
| Enumeration Date | 2005-07-14 |
| Last Update Date | 2015-05-05 |