| NPI | 1962408674 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 213E00000X Podiatrist (Licence: AR 178) |
| Additional Taxonomies | 213E00000X Podiatrist (Licence: TX 1369) |
| 213E00000X Podiatrist (Licence: FL P0002214) | |
| Enumeration Date | 2005-06-27 |
| Last Update Date | 2013-04-01 |