| NPI | 1811063134 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 208600000X Surgery (Licence: VA 0101039629) | 
| Additional Taxonomies | 208600000X Surgery (Licence: MD D0033962) | 
| 208600000X Surgery (Licence: DC MD15261) | |
| Enumeration Date | 2006-11-28 | 
| Last Update Date | 2011-10-24 |