| NPI | 1790776995 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207N00000X Dermatology (Licence: FL ME118627) |
| Additional Taxonomies | 207N00000X Dermatology (Licence: MI 4301069802) |
| Enumeration Date | 2005-11-04 |
| Last Update Date | 2015-06-22 |