Name:

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Type of Practice:

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Medical School:

Graduation year from medical school:

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Practice Type:

Classification:

Specialization:

Definition of Specialty:

License #(s):

License State(s):

Practice Location:

Mailing Address:

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Practice location fax #:

Mailing address Phone #:

Mailing Address fax #:

Authorized official Name/Telephone #:

Date NPI was obtained:

Last data data was updated:

Insurances: