| Name | Value |
|---|---|
| PROVIDER TYPE | Physicians (M.D. and D.O.) |
| CLASSIFICATION | Surgery, Plastic Facial, Otolaryngology |
| STATUS | Inactive |
| DATE INACTIVATED | 1998-10-20 00:00:00 |
| VA CODE | V117600 |
| reserved | P75 |
| INDIVIDUAL/NON | INDIVIDUAL |
| MASTER ENTRY FOR VUID | YES |
| VUID | 5254118 |
| EFFECTIVE DATE/TIME |
|