| NPI | 1790757490 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: OH 36002569) |
| Additional Taxonomies | 213E00000X Podiatrist (Licence: WV 00239) |
| Enumeration Date | 2006-02-06 |
| Last Update Date | 2014-03-19 |