| NPI | 1679517858 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: AZ 45521) |
| Additional Taxonomies | 207R00000X Internal Medicine (Licence: AZ 45521) |
| 207R00000X Internal Medicine (Licence: MP 0407) | |
| 208000000X Pediatrics (Licence: MP 0407) | |
| 261QP2300X Clinic/Center, Primary Care (Licence: AZ 45521) | |
| Enumeration Date | 2006-06-16 |
| Last Update Date | 2020-07-10 |