| NPI | 1912166323 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 174400000X Specialist (Licence: NY 248691) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: NY 248691) |
| 261QC1800X Clinic/Center, Corporate Health (Licence: NY 248691) | |
| Enumeration Date | 2008-06-02 |
| Last Update Date | 2018-02-19 |