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Individual
PHA C LE
Active
Individual
PHA C LE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.O.
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
036115367
IL
207P00000X
Emergency Medicine Physician
Primary
20A9993
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
20A 9990
STATE LICENSE
CA
Enumeration date
08/02/2006
Last updated
08/19/2021
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