| NPI | 1962687384 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: SC MD9312) |
| Additional Taxonomies | 261QP2300X Clinic/Center Primary Care (Licence: SC 9312) |
| 208D00000X General Practice (Licence: SC MD9312) | |
| Enumeration Date | 2008-01-03 |
| Last Update Date | 2013-12-17 |