| NPI | 1790117893 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213ES0103X Podiatrist, Foot & Ankle Surgery (Licence: TX 2205) |
| Additional Taxonomies | 213E00000X Podiatrist (Licence: TX 2205) |
| 332B00000X Durable Medical Equipment & Medical Supplies | |
| 335E00000X Prosthetic/Orthotic Supplier | |
| Enumeration Date | 2013-07-31 |
| Last Update Date | 2018-03-17 |