| NPI | 1669730008 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: MI 4301101902) |
| Additional Taxonomies | 208D00000X General Practice (Licence: OH 127592) |
| Enumeration Date | 2012-04-23 |
| Last Update Date | 2026-03-20 |