Registry details
Type
Individual
Primary specialty
Psychiatry & Neurology, Neurology
Enumerated
Jul 11, 2016
License(s)
OS20880 (FL), OS20880 (FL), OT017378 (PA), OP61551212 (WA), 78903 (GA)
Addresses on file
| Purpose | Address | City/State | Phone |
|---|---|---|---|
| LOCATION | 11215 METRO PKWY STE 100 | Fort Myers, FL 33966-1206 | 239-208-2206 |
| MAILING | 2652 29TH ST APT 1A | Astoria, NY 11102-2162 | 770-861-1978 |
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