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Individual
TRI LE
Active
Individual
TRI LE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
2020029935
MO
207Q00000X
Family Medicine Physician
35123035
OH
207Q00000X
Family Medicine Physician
Primary
ME165672
FL
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
05/29/2012
Last updated
02/23/2024
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