| NPI | 1811421514 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: IL 036.163255) |
| Additional Taxonomies | 208D00000X General Practice (Licence: AZ 68132) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| 208D00000X General Practice (Licence: UT 11809435-1205) | |
| 208D00000X General Practice (Licence: FL ME165629) | |
| Enumeration Date | 2017-04-19 |
| Last Update Date | 2025-09-15 |