| NPI | 1669706578 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: CT 051335) |
| Additional Taxonomies | 261QU0200X Clinic/Center, Urgent Care (Licence: CT 051335) |
| 207Q00000X Family Medicine (Licence: NY 254500) | |
| Enumeration Date | 2009-09-24 |
| Last Update Date | 2019-02-04 |