| NPI | 1780644070 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: FL ME103068) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: NY 1383591) |
| Enumeration Date | 2006-03-23 |
| Last Update Date | 2014-08-27 |