| NPI | 1790761088 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: FL PO1844) |
| Additional Taxonomies | 213E00000X Podiatrist (Licence: NY N004176) |
| Enumeration Date | 2005-12-19 |
| Last Update Date | 2008-04-16 |