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NPI 1124935721 · on the registry since 2026

Practice

Address
12613 Lunan Rd
Clinton, MD 20735
Phone
(240) 354-5211

Registry record

Primary taxonomy
172V00000X
172V00000X
Licence states on file
MD
From the registry's licence fields, which are often incomplete.
Sex
Male
Record last updated
2026-08-27

Source: CMS National Plan and Provider Enumeration System. Registration is not the same as practising, and the registry records no retirement — some people listed here no longer practise. More in Maryland