| NPI | 1811105745 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207N00000X Dermatology (Licence: UT 7153621-1205) |
| Additional Taxonomies | 207N00000X Dermatology (Licence: PA MT187813) |
| Enumeration Date | 2007-05-21 |
| Last Update Date | 2009-06-19 |