| NPI | 1851719264 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: OR MD195395) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: OH 35.129600) |
| Enumeration Date | 2014-04-02 |
| Last Update Date | 2025-11-12 |