Active
Details
NPI: 1851786925
Email: —
Phone: —
Role: prescriber
Entities (1)
Licenses (29)
| Jurisdiction | Type | License # | Status | Expires | Verified |
|---|---|---|---|---|---|
| AL | medical license | 47652 | unknown | 2024-12-31 | unverified |
| AZ | medical license | 72021 | unknown | 2025-06-16 | unverified |
| CA | medical license | — | pending | — | unverified |
| CO | medical license | CDR.0003383 | unknown | 2025-04-30 | unverified |
| CT | medical license | 076541 | unknown | 2025-02-28 | unverified |
| DC | medical license | MD500002556 | unknown | 2024-12-31 | unverified |
| DE | medical license | C1-0026588 | unknown | 2025-03-31 | unverified |
| FL | medical license | ME135844 | unknown | 2026-01-31 | unverified |
| GA | medical license | 079770 | unknown | 2025-02-28 | unverified |
| ME | medical license | MD27767 | unknown | 2025-02-28 | unverified |
| MI | medical license | EMC0004221 | unknown | 2026-11-13 | unverified |
| MN | medical license | 75655 | unknown | 2025-02-28 | unverified |
| MT | medical license | MED-PHYS-COM-LIC-131426 | unknown | 2025-03-31 | unverified |
| ND | medical license | 20454 | unknown | 2025-02-16 | unverified |
| NE | medical license | CP471 | unknown | 2024-10-01 | unverified |
| NH | medical license | 25178 | unknown | 2025-11-28 | unverified |
| NJ | medical license | — | pending | — | unverified |
| NM | medical license | MD2019-0952 | unknown | 2026-07-01 | unverified |
| NV | medical license | 24697 | unknown | 2025-06-30 | unverified |
| NY | medical license | — | pending | — | unverified |
| US | npi | 1851786925 | active | — | verified |
| US | dea | FP7466231 | active | 2027-03-31 | unverified |
| UT | medical license | 13678522-1235 | unknown | 2026-01-31 | unverified |
| VA | medical license | — | pending | — | unverified |
| VT | medical license | 042.0017480 | unknown | 2024-11-30 | unverified |
| WA | medical license | IMLCC.MD.61505033 | unknown | 2026-02-16 | unverified |
| WI | medical license | 3711-320 | unknown | 2025-10-31 | unverified |
| WV | medical license | 33219 | unknown | 2025-06-30 | unverified |
| WY | medical license | 16438C | unknown | 2024-06-30 | unverified |
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