Individual
Inactive
Sole proprietor
Provider details
NPI number
Contact information
Taxonomy
Speciality
Code
Description
License number
State
208D00000X
General Practice Physician
Primary
A38614
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00A386140
—
CA
01
—
A38614
STATE LIC
CA
Enumeration date
—
Last updated
—
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