| NPI | 1780856500 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: UT 8147213-1205) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: MO 2007008864) |
| Enumeration Date | 2008-04-01 |
| Last Update Date | 2012-10-09 |