| NPI | 1770634909 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207N00000X Dermatology (Licence: UT 7247463-1204) |
| Additional Taxonomies | 207N00000X Dermatology (Licence: WI 47784-021) |
| Enumeration Date | 2007-01-15 |
| Last Update Date | 2018-04-13 |