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Individual
L TAN
Active
Individual
L TAN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Taxonomy
Speciality
Code
Description
License number
State
208800000X
Urology Physician
ME33964
FL
208D00000X
General Practice Physician
Primary
ME33964
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
123513762
NPI
FL
Enumeration date
05/30/2005
Last updated
07/18/2026
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