| NPI | 1922082957 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: KY 119) |
| Additional Taxonomies | 213E00000X Podiatrist (Licence: IN 07000335A) |
| 213ES0000X Podiatrist, Sports Medicine (Licence: KY 00119) | |
| 332BC3200X Durable Medical Equipment & Medical Supplies, Customized Equipment | |
| Enumeration Date | 2005-12-02 |
| Last Update Date | 2015-10-06 |