Individual
SOE NYUNT
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
2121 LAKE AVE, FORT WAYNE, IN 46805-5100
(260) 426-5431
Mailing address
5712 RIO CANYON RUN, FORT WAYNE, IN 46825-1406
(260) 470-9673
(260) 470-9673
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
217934
NY
Other
Enumeration date
10/19/2006
Last updated
04/26/2013
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