| NPI | 1922015742 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 174400000X Specialist (Licence: TX E4458) |
| Additional Taxonomies | 261QM2500X Clinic/Center Medical Specialty (Licence: TX E4458) |
| Enumeration Date | 2006-08-02 |
| Last Update Date | 2007-07-08 |