| NPI | 1740482603 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | Yes | 
| Primary Taxonomy | 207ND0101X Dermatology, MOHS-Micrographic Surgery (Licence: CA A107638)  | 
| Additional Taxonomies | 207N00000X Dermatology (Licence: OH 57.010897)  | 
| 207ND0101X Dermatology, MOHS-Micrographic Surgery (Licence: NY 248179)  | |
| Enumeration Date | 2007-06-04 | 
| Last Update Date | 2009-07-26 |