| NPI | 1902011943 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QS0010X Family Medicine, Sports Medicine (Licence: IL 036.133898) |
| Additional Taxonomies | 207R00000X Internal Medicine (Licence: OH 35.094147) |
| 208000000X Pediatrics (Licence: OH 35.094147) | |
| Enumeration Date | 2007-05-12 |
| Last Update Date | 2014-11-17 |