| NPI | 1770681058 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: TX 1576) |
| Additional Taxonomies | 213ES0103X Podiatrist, Foot & Ankle Surgery (Licence: TX 1576P) |
| 332B00000X Durable Medical Equipment & Medical Supplies | |
| Enumeration Date | 2006-09-20 |
| Last Update Date | 2021-05-04 |