| NPI | 1700867272 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: AL 00017192) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: GA 038916) |
| Enumeration Date | 2005-11-10 |
| Last Update Date | 2012-10-03 |