| NPI | 1740261684 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: MI 4301116553) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: NC 93-00374) |
| Enumeration Date | 2005-11-08 |
| Last Update Date | 2025-10-13 |