| NPI | 1902800931 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207R00000X Internal Medicine (Licence: WV 11609) |
| Additional Taxonomies | 208D00000X General Practice (Licence: WV 11609) |
| Enumeration Date | 2005-06-08 |
| Last Update Date | 2012-01-18 |