| NPI | 1902000995 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2086S0129X (Licence: NY 257864) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NY 257864-1) |
| 2086S0129X (Licence: OH 35.092142) | |
| 2086S0129X (Licence: NJ 25MA09006600) | |
| 2086S0129X (Licence: CT 048880) | |
| Enumeration Date | 2007-06-13 |
| Last Update Date | 2018-10-15 |