Individual
Inactive
Sole proprietor
Provider details
NPI number
Contact information
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
ME 0063346
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
373855800
—
FL
01
—
593669300
FEIN
FL
Enumeration date
—
Last updated
—
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