| NPI | 1760687016 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: NY 228145) |
| Additional Taxonomies | 208D00000X General Practice (Licence: GA 051805) |
| Enumeration Date | 2007-06-18 |
| Last Update Date | 2009-11-12 |