Individual
Inactive
Sole proprietor
Provider details
NPI number
Contact information
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
D0040363
MD
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
090161000
—
MD
05
—
413046400
—
MD
01
—
P00430515
RAILROAD
MD
Enumeration date
—
Last updated
—
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