| NPI | 1790789717 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: TN MD8478) |
| Additional Taxonomies | 208D00000X General Practice (Licence: GA MD019572) |
| Enumeration Date | 2005-06-08 |
| Last Update Date | 2009-02-19 |