| NPI | 1871665042 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: TX 0636) |
| Additional Taxonomies | 213ES0131X Podiatrist, Foot Surgery (Licence: TX 0636) |
| 332B00000X Durable Medical Equipment & Medical Supplies (Licence: TX 0636) | |
| Enumeration Date | 2006-11-14 |
| Last Update Date | 2007-10-25 |