| NPI | 1912535964 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MI 5101029455) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: IL 036165695) |
| Enumeration Date | 2020-03-27 |
| Last Update Date | 2026-10-01 |