š Key Takeaways
- The largest, most rigorous D-mannose trial to date (Hayward 2024, N=598) found no reduction in UTI recurrence versus placebo in women with recurrent UTIs treated in primary care.[1]
- The 2025 AUA/CUA/SUFU guideline amendment now formally states that D-mannose alone "may not be effective" for UTI prevention. Cranberry was upgraded to a "should offer" recommendation, and methenamine hippurate was added as an option.[2]
- For peri- and postmenopausal women, low-dose vaginal estrogen is the highest-impact non-antibiotic option. The FDA removed the boxed warning from menopausal hormone therapy in November 2025 to reflect updated safety evidence.[3][4]
- Cranberry products reduce UTI risk by roughly 30% in women with recurrent UTIs, per a 2023 Cochrane review of 50 trials.[5] The magnitude is modest, but the evidence base is real.
- Methenamine hippurate was non-inferior to daily low-dose antibiotics for preventing recurrent UTIs in the ALTAR trial and produces less antibiotic resistance.[6]
- Two new oral antibiotics for uncomplicated UTIs, pivmecillinam (Pivya, 2024) and gepotidacin (Blujepa, 2025), expanded treatment options for the first time in decades.[7][8]
- Brand-name UTI supplement blends (Uqora, Utiva, AZO Cranberry) rely mostly on ingredient-level evidence and marketing claims, not product-specific trials.
What Is D-Mannose, and Why Was Everyone Taking It?
D-mannose is a simple sugar, chemically similar to glucose. In the body, it is filtered by the kidneys and excreted in the urine largely unmetabolized. The theory behind its use in UTIs is elegant: E. coli, which causes about 80% of uncomplicated UTIs, binds to the bladder wall via a protein called FimH that has a strong affinity for mannose. In test-tube and animal studies, D-mannose in urine appears to coat those bacterial adhesins so the bacteria wash out with the next void instead of climbing further up the urinary tract.[9]
The mechanism is real, and it made D-mannose the darling of the UTI supplement aisle for a decade. Then came the trial that mattered.
What Changed in 2024 to 2026
Three developments reshaped the practical answer to "what should I take to prevent UTIs":
- April 2024: JAMA Internal Medicine published the Hayward MERIT trial, the largest and most rigorously designed D-mannose RCT to date. It found no benefit versus placebo.[1]
- September 2025: The American Urological Association, Canadian Urological Association, and Society of Urodynamics amended their joint recurrent-UTI guideline. Cranberry was upgraded, methenamine hippurate was added, and D-mannose alone was formally recommended against.[2]
- November 2025: The FDA removed the boxed warning from menopausal hormone therapy products, including low-dose vaginal estrogen, based on updated safety data. Only the endometrial-cancer boxed warning for systemic estrogen-alone products in women with a uterus remains.[3][4]
In parallel, two new oral antibiotics were approved for uncomplicated UTIs: pivmecillinam (Pivya) in April 2024 and gepotidacin (Blujepa) in March 2025.[7][8] Both are relevant for women whose infections are resistant to first-line agents.
The Hayward Trial: What It Actually Showed
Before 2024, the strongest positive evidence for D-mannose came from KranjÄec 2014, a single-center Croatian trial in 308 women that compared D-mannose 2 g daily to no prophylaxis and to nitrofurantoin. Recurrence rates were 14.6% for D-mannose, 20.4% for nitrofurantoin, and 60.8% for no treatment.[10] The numbers were striking, but the trial was small, open-label, single-center, and used no prophylaxis rather than placebo as the comparator, which is a bar D-mannose could clear on hydration alone.
The Hayward MERIT trial fixed those problems.[1] It enrolled 598 women in UK primary care with a history of recurrent UTIs, randomized them to D-mannose 2 g daily or placebo for six months, and asked the pragmatic question that matters most: did they contact ambulatory care for another UTI?
The results: 51.0% of the D-mannose group had another clinically suspected UTI, versus 55.7% of the placebo group. The relative risk was 0.92 with a 95% confidence interval of 0.80 to 1.05, and the confidence interval crossed the threshold that a prespecified patient advisory panel had said would be meaningful.[1] Secondary outcomes for antibiotic use, hospital admission, and time to next UTI were similarly null.
The authors' conclusion, verbatim: "Daily D-mannose should not be recommended to prevent future episodes of clinically suspected UTI in women with rUTI in primary care."[1]
This is not the last word. Combination products with cranberry or probiotics, higher doses, or use for acute cystitis symptoms may still have signal. But for the specific, high-volume question "should I take D-mannose to prevent my next UTI," the answer changed.
The 2025 AUA Guideline Stance
In September 2025 the AUA, CUA, and SUFU jointly amended their recurrent-UTI guideline for the first time since 2022.[2] The changes to non-antibiotic prophylaxis were substantive:
- Recommendation 13, cranberry: Upgraded from "clinicians may offer" to "clinicians should offer" as a prophylaxis option (Moderate Recommendation, Grade B).
- Recommendation 14, D-mannose: New. Clinicians should inform patients with recurrent UTIs that D-mannose alone "may not be effective in UTI prevention" (Moderate Recommendation, Grade B).
- Recommendation 15, methenamine hippurate: New. Clinicians may offer methenamine hippurate for prophylaxis (Conditional Recommendation, Grade C).
- Recommendation 16, water intake: New. In women with fluid intake below 1.5 L/day, clinicians may recommend increased water intake (Conditional Recommendation).
The vaginal estrogen recommendation for peri- and postmenopausal women, unchanged from prior versions, remains a Strong Recommendation.
How Prevention Options Compare
The graph below sizes up the four best-studied non-antibiotic options against each other using midpoint effect estimates from their strongest trials. These are approximations for orientation, not head-to-head comparisons, since the trials enrolled different populations and used different outcome definitions.
| Option | Typical dose | Best-evidence effect | Who benefits most | Approximate monthly cost |
|---|---|---|---|---|
| Low-dose vaginal estrogen | Estradiol 10 mcg tablet or cream, nightly × 2 weeks then 2 to 3 times weekly | ~50 to 75% reduction in recurrent UTIs | Peri- and postmenopausal women, especially with GSM symptoms | $25 to $60 with insurance |
| Methenamine hippurate | 1 g twice daily | Non-inferior to daily low-dose antibiotics (ALTAR trial) | Women avoiding daily antibiotics, no severe renal or hepatic disease | $20 to $40 generic |
| Cranberry products | 36 to 72 mg PACs daily, or 240 to 300 mL juice twice daily | ~30% reduction in women with recurrent UTIs (Cochrane 2023) | Otherwise healthy women with 2+ UTIs per year | $10 to $30 |
| Post-coital single-dose antibiotic | TMP-SMX or nitrofurantoin, one dose within 2 hours after sex | >90% reduction if UTIs are sex-associated | Women with clear post-coital timing | $5 to $15 generic |
| Increased water intake | Additional 1.5 L/day if baseline low | ~48% reduction in low-intake women (Hooton 2018) | Women drinking less than about 1.5 L/day | Free |
| D-mannose alone | 2 g daily | RR 0.92, not statistically significant (Hayward 2024) | No population with rigorous evidence of benefit | $15 to $30 |
| Your situation | Consider first | Why |
|---|---|---|
| Peri- or postmenopausal woman with recurrent UTIs | Low-dose vaginal estrogen | Strongest effect size (~50 to 75% reduction), Strong AUA recommendation, boxed warning removed 2025 |
| Premenopausal woman, UTIs cluster after sex | Post-coital single-dose antibiotic | >90% reduction when timing is clear; minimal exposure |
| Recurrent UTIs, wants to avoid daily antibiotics | Methenamine hippurate 1 g twice daily | Non-inferior to daily antibiotic prophylaxis; no antibiotic resistance pressure |
| Otherwise healthy, 2 to 3 UTIs per year, mild pattern | Standardized cranberry (36+ mg PACs/day) plus hydration | ~30% reduction on rigorous meta-analysis; low-risk starting point |
| Baseline fluid intake below 1.5 L/day | Add 1.5 L of water daily | ~48% reduction in the Hooton 2018 trial; free |
| UTIs resistant to nitrofurantoin, TMP-SMX, and fosfomycin | Discuss pivmecillinam (Pivya) or gepotidacin (Blujepa) for treatment | New oral options for resistant uncomplicated UTIs |
Cranberry: The Modest but Real Evidence
Cranberry is the poster child for a supplement that was overhyped, dismissed, and then partially rehabilitated. The FDA in 2020 concluded there was "limited credible scientific evidence" for a UTI risk-reduction claim on cranberry products.[11] Three years later, the 2023 Cochrane review of 50 randomized trials in 8,857 people found cranberry products reduced the risk of symptomatic, culture-verified UTIs by 30% overall (RR 0.70, 95% CI 0.58 to 0.84).[5]
The benefit is real but selective. Cranberry helped women with recurrent UTIs, children with UTIs, and people undergoing procedures like bladder radiotherapy. It did not help elderly institutionalized adults, adults with neurogenic bladder or incomplete emptying, or pregnant women.[5]
The active ingredients are A-type proanthocyanidins (PACs), which interfere with E. coli adhesion. Practical guidance: look for products standardized to at least 36 mg PACs daily. Juice works if you tolerate the sugar and volume, but capsules and tablets are more consistent. AZO Cranberry, Ellura, Theracran HP, and Utiva all publish PAC content.
Methenamine Hippurate: An Old Drug Making a Comeback
Methenamine hippurate is a prescription urinary antiseptic that has been on the market for decades. It gets excreted into urine and, in an acidic environment, releases small amounts of formaldehyde that suppress bacterial growth. It does not act as a systemic antibiotic and does not select for the same resistance patterns.
The 2022 ALTAR trial in BMJ randomized 240 UK women with recurrent UTIs to methenamine hippurate 1 g twice daily or daily low-dose antibiotic prophylaxis. Over 12 months, symptomatic UTI rates were 0.89 episodes per person-year on methenamine versus 1.38 on antibiotics, meeting non-inferiority.[6] The methenamine arm also showed fewer antibiotic-resistant urinary isolates at trial exit.
The tradeoffs: it does not treat active infection, only prevents new ones. It is contraindicated in patients with severe hepatic or renal impairment and in gout with hyperuricemia. Some patients need supplemental vitamin C to acidify their urine below pH 5.5 for the drug to work, though evidence for routine acidification is weak. It is a reasonable option for women who want to avoid daily antibiotic prophylaxis and are not postmenopausal candidates for vaginal estrogen.
Vaginal Estrogen: The Highest-Impact Option Postmenopause
If you are peri- or postmenopausal and having recurrent UTIs, the single highest-yield intervention is almost certainly low-dose vaginal estrogen, not a supplement. Estrogen deficiency in the vaginal and periurethral tissue is a mechanistic driver of UTI recurrence, and restoring local estrogen restores healthy lactobacilli, tissue thickness, and pH.
Randomized trials and multiple meta-analyses show approximately 50 to 75% reduction in UTI recurrence with consistent use.[12] The 2019 (confirmed 2022, amended 2025) AUA guideline gives this a Strong Recommendation.[2] The 2024 AUA/SUFU/AUGS guideline on genitourinary syndrome of menopause reinforces the same point.[13]
Safety was the main reason women (and some clinicians) avoided it for two decades. In November 2025 the FDA acted on updated evidence and removed the boxed warning from menopausal hormone therapy products, including low-dose vaginal estrogen. The only boxed warning that remains is for endometrial cancer risk on systemic estrogen-alone products used by women who still have a uterus, which does not apply to low-dose local vaginal products.[3][4]
Typical dosing: estradiol 10 mcg vaginal tablet nightly for 2 weeks, then 2 to 3 times weekly indefinitely. Cream, ring, and tablet formulations are equivalent. Vaginal estrogen can be prescribed via a synchronous telehealth visit in all 50 U.S. states.
Probiotics and Lactobacillus: An Emerging Story
Healthy premenopausal vaginal flora is dominated by Lactobacillus species, which acidify vaginal pH and compete with uropathogens. The theory is that oral or vaginal probiotics can restore this ecosystem in women with recurrent UTIs. The best trial evidence to date is the 2011 Stapleton RCT of Lactobacillus crispatus CTV-05, an intravaginal suppository given to women with a history of recurrent UTIs. The recurrence rate was 15% with CTV-05 versus 27% with placebo over 10 weeks (RR 0.5).[14]
CTV-05 is not currently available as a consumer product. Most over-the-counter oral probiotics with generic Lactobacillus rhamnosus or Lactobacillus reuteri strains do not have UTI-specific trial data. Oral probiotics are safe in most people, but the evidence for UTI-specific benefit from a bottle at CVS is thin. If you want to try one, choose a strain with published human trial data and set expectations accordingly.
The New Antibiotics: Pivya and Blujepa
Two oral antibiotics were approved for uncomplicated UTIs in the last two years, and both are useful when first-line agents fail or resistance is known.
Pivmecillinam (Pivya) was FDA-approved in April 2024 for female patients 18 and older with uncomplicated UTIs caused by susceptible E. coli, Proteus mirabilis, and Staphylococcus saprophyticus. Standard dose is 185 mg orally three times daily for 3 to 7 days.[7] Pivmecillinam has been widely used in Europe for four decades and is a first-line agent in Nordic countries. It is a beta-lactam with a narrow spectrum, which limits collateral resistance selection.
Gepotidacin (Blujepa) was FDA-approved in March 2025 for female adults and adolescents 12 and older with uncomplicated UTIs, marking the first new antibiotic class for UTIs in nearly three decades. Standard dose is 1,500 mg (two 750 mg tablets) orally twice daily for 5 days. The pivotal EAGLE-2 and EAGLE-3 trials showed non-inferiority to nitrofurantoin, and in one endpoint gepotidacin was statistically superior (58.5% therapeutic success vs 43.6% for nitrofurantoin).[8] Common adverse effects are mostly mild gastrointestinal.
Neither is a first-line choice for a straightforward first UTI. Both matter for women with recurrent UTIs whose organisms are resistant to nitrofurantoin, TMP-SMX, and fosfomycin.
Uqora, Utiva, AZO, and Other Brand Blends
Consumer UTI supplement brands mostly package familiar ingredients into proprietary blends. Their marketing claims are typically stronger than their evidence.
- Uqora Target and Control: D-mannose plus vitamin B6, calcium, and other cofactors. A company-funded 2024 open-label study evaluated the ingredients (NCT04024046), but there is no independent placebo-controlled trial of the branded product as a whole.
- Utiva Cranberry PACs: 36 mg PACs per capsule, standardized. This is an evidence-grade cranberry product, and the dose is defensible on the Cochrane data.
- AZO Cranberry Softgels: Available OTC in most pharmacies, PAC content varies by SKU. Reasonable if PAC content on the label is at least 36 mg.
- AZO Urinary Pain Relief: Contains phenazopyridine, which numbs the bladder for symptom relief. It is not a treatment, only a bandage. It can also cause false positives on nitrite dipstick tests and should be stopped before urine testing.
Under FDA rules, dietary supplements cannot claim to "prevent" or "treat" a disease. Many of these brands push those boundaries in their marketing while the product label carries the standard "not intended to diagnose, treat, cure, or prevent any disease" disclaimer.[15]
What Does Not Work
A short list of things patients frequently ask about that do not have credible evidence for UTI prevention or treatment:
- Vitamin C at supplement doses. Popular theory: acidifies urine and inhibits bacteria. Reality: dietary or oral supplement vitamin C does not lower urine pH enough to be antibacterial, and it can produce false-negative nitrite dipstick tests.
- Apple cider vinegar. No credible evidence in humans. It will not sterilize your urine.
- Baking soda. Old folk remedy that alkalinizes urine and can provide brief symptom relief for burning, but it does not treat infection. Sodium load is a real concern in patients with hypertension, heart failure, or kidney disease.
- Colloidal silver. No evidence, and chronic use can cause irreversible skin discoloration (argyria).
- Uva ursi (bearberry). Contains arbutin, which is metabolized to hydroquinone. Short-term safety is acceptable in some regulatory frameworks, but hydroquinone carries theoretical carcinogenicity concerns, and no rigorous trial supports use for UTI prevention.
- Garlic supplements. Popular in wellness content, no meaningful trial evidence for UTIs.
- Wiping direction. The classic "front to back" advice has no controlled-trial support for preventing UTIs. Not harmful, just not evidence-based.
Contraindications and Safety
| Intervention | Avoid or use caution | Notable interactions |
|---|---|---|
| D-mannose | Diabetes (mild osmotic effect and small caloric load); pregnancy (insufficient data) | None clinically significant |
| Cranberry products | History of oxalate kidney stones (juice more than concentrate) | Warfarin: small effect on INR; monitor if starting |
| Methenamine hippurate | Severe renal or hepatic impairment; gout with hyperuricemia | Sulfonamides (may precipitate in urine); avoid concurrent |
| Low-dose vaginal estrogen | Active or recent breast/endometrial cancer requires oncology co-management; undiagnosed vaginal bleeding | Aromatase inhibitor therapy: shared decision-making with oncologist |
| Post-coital antibiotic | Fluoroquinolone allergy or tendinopathy risk | See specific agent (TMP-SMX with warfarin, methotrexate) |
Red Flags: When to Contact a Clinician
Supplement questions are usually not urgent. UTI symptoms sometimes are. Seek prompt evaluation for any of the following:
- Fever above 100.4Ā°F (38Ā°C), flank or back pain, nausea, or vomiting with urinary symptoms. These suggest pyelonephritis.
- Blood in the urine that is more than a trace, especially in men, women over 40, or anyone with tobacco exposure.
- Symptoms during pregnancy at any trimester.
- Symptoms that persist or worsen after 48 hours of an antibiotic that should be effective.
- New symptoms in a man of any age (UTI in healthy adult men is uncommon and usually requires further evaluation).
- New symptoms after urinary tract instrumentation, catheterization, or stone passage.
- Recurrent UTIs that are not responding to standard preventive measures.
Symptomatic UTIs in otherwise healthy adult women can typically be diagnosed and treated through a telehealth visit in all 50 U.S. states. Complicated cases, pediatric patients, and pyelonephritis usually need in-person evaluation.
Frequently Asked Questions
Not necessarily. If you have been taking D-mannose and feel it helps, it is unlikely to be harmful, and the 2025 AUA guideline notes it is "unlikely to do harm."[2] What changed is the expectation: the largest rigorous trial says you should not expect a meaningful reduction in your recurrence rate compared with placebo. If you are getting recurrent UTIs and D-mannose is your only prevention strategy, that is a conversation worth having with a clinician, because better-supported options exist.
Combinations have not been shown to add benefit over the individual ingredients with the strongest evidence. If you take a combination product, the cranberry component is where the real evidence is, so check the PAC content on the label. Aim for at least 36 mg of proanthocyanidins per day.
The typical dose studied is 2 g daily, sometimes divided. Higher doses can cause loose stools, bloating, or flatulence. D-mannose has not been studied in pregnancy. In diabetes, the caloric contribution and osmotic effect are small but not zero, so it is worth discussing with your clinician.
Yes, if your baseline intake is low. The 2018 Hooton trial randomized women with recurrent UTIs and low fluid intake (below 1.5 L/day) to an extra 1.5 L of water daily; UTI recurrence dropped by about 48% over 12 months. The 2025 AUA amendment now recommends this for women with baseline intake below 1.5 L/day. If you already drink 2+ liters, adding more probably will not help much.
Either works, provided you get enough of the active ingredient. Standardized capsules make the dose more predictable and skip the sugar of most cranberry juice cocktails. If you prefer juice, choose unsweetened 100% cranberry juice and take roughly 240 to 300 mL twice daily.
If she is postmenopausal, low-dose vaginal estrogen is the single most impactful evidence-based option, with roughly 50 to 75% reduction in recurrent UTIs and now much clearer safety data since the FDA removed the boxed warning in November 2025. A hysterectomy without breast cancer contraindication makes her an especially straightforward candidate. This is a prescription conversation worth having.
Methenamine hippurate is technically a urinary antiseptic, not a systemic antibiotic. Once excreted into acidic urine, it releases small amounts of formaldehyde that suppress bacterial growth locally. Because the mechanism is nonspecific and topical to the urine, it does not select for the same resistance patterns as fluoroquinolones or TMP-SMX. It is prevention only, not treatment for an active UTI.
They are not first-line for a straightforward first UTI, and both are more expensive than generic nitrofurantoin or TMP-SMX. They are worth asking about if your infections have been resistant to standard oral options or if you have had bad reactions to first-line agents. Availability and insurance coverage are still catching up, especially for gepotidacin.
There is no clinically significant drug interaction between Uqora's ingredients and the antibiotics typically used for UTIs, but there is also no evidence that adding it improves outcomes. If you are on an antibiotic for an active UTI, focus on completing that course. Supplement decisions can wait.
They can, with limits. Home dipstick strips (nitrite plus leukocyte esterase) are 75 to 90% sensitive; a positive result in a woman with typical symptoms is highly suggestive. A negative result does not rule out a UTI, since some common organisms do not produce nitrites. See our companion review of at-home strips for accuracy details.
The standard definition is 2 or more culture-confirmed UTIs in 6 months, or 3 or more in 12 months. At that threshold, the AUA guideline recommends a discussion about prevention strategies, and for postmenopausal women, vaginal estrogen becomes a first consideration.
Vaginal estrogen, methenamine hippurate, post-coital single-dose antibiotics, and treatment-course antibiotics for uncomplicated UTIs can all be prescribed via a synchronous telehealth visit in all 50 U.S. states after appropriate history and shared decision-making. Complicated UTI, pyelonephritis, pregnancy-related UTI, and pediatric UTI generally require in-person evaluation.
References
- Hayward G, Mort S, Hay AD, et al. d-Mannose for Prevention of Recurrent Urinary Tract Infection Among Women: A Randomized Clinical Trial. JAMA Intern Med. 2024;184(6):619-628. PubMed 38587819.
- American Urological Association, Canadian Urological Association, Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction. Recurrent Uncomplicated Urinary Tract Infections in Women: AUA/CUA/SUFU Guideline (2019, Confirmed 2022, Amended 2025). AUA Guideline PDF (2025 amendment).
- U.S. Food and Drug Administration. FDA Approves Labeling Changes to Menopausal Hormone Therapy Products (removal of boxed warnings). Press announcement, November 2025. FDA news release.
- American Urogynecologic Society. Practice Advisory: Removal of Black Box Warning Label from Topical Low-Dose Vaginal Estrogen Products. December 2025. AUGS practice advisory (PDF).
- Williams G, Hahn D, Stephens JH, Craig JC, Hodson EM. Cranberries for preventing urinary tract infections. Cochrane Database Syst Rev. 2023;4(4):CD001321. PubMed 37068952.
- Harding C, Chadwick T, Homer T, et al. Methenamine hippurate compared with antibiotic prophylaxis to prevent recurrent urinary tract infections in women: the ALTAR non-inferiority RCT. Health Technol Assess. 2022;26(23):1-172. PubMed 35535708.
- U.S. Food and Drug Administration. PIVYA (pivmecillinam) tablets prescribing information. Initial U.S. approval 2024. FDA label (PDF).
- U.S. Food and Drug Administration. BLUJEPA (gepotidacin) tablets prescribing information. Initial U.S. approval 2025. FDA label (PDF).
- Ala-Jaakkola R, Laitila A, Ouwehand AC, Lehtoranta L. Role of D-mannose in urinary tract infections: a narrative review. Nutr J. 2022;21(1):18. PubMed 35313893.
- Kranjčec B, PapeÅ” D, Altarac S. D-mannose powder for prophylaxis of recurrent urinary tract infections in women: a randomized clinical trial. World J Urol. 2014;32(1):79-84. PubMed 23633128.
- U.S. Food and Drug Administration. Qualified Health Claim: Cranberry Juice Beverages, Cranberry Dietary Supplements, and Urinary Tract Infections in Women. FDA response letter, July 2020. FDA statement.
- Ferrante KL, Wasenda EJ, Jung CE, Adams-Piper ER, Lukacz ES. Vaginal Estrogen for the Prevention of Recurrent Urinary Tract Infection in Postmenopausal Women: A Randomized Clinical Trial. Female Pelvic Med Reconstr Surg. 2021;27(2):112-117. PubMed 31232721.
- Kaufman MR, Ackerman AL, Amin KA, et al. The AUA/SUFU/AUGS Guideline on Genitourinary Syndrome of Menopause. J Urol. 2025;214(3):242-250. PubMed 40298120.
- Stapleton AE, Au-Yeung M, Hooton TM, et al. Randomized, placebo-controlled phase 2 trial of a Lactobacillus crispatus probiotic given intravaginally for prevention of recurrent urinary tract infection. Clin Infect Dis. 2011;52(10):1212-1217. PubMed 21498386.
- U.S. Food and Drug Administration. Structure/Function Claims for Dietary Supplements. Guidance for Industry. FDA guidance.
About the Author
Parth Bhavsar, MD is a board-certified family medicine physician and the founder of TeleDirectMD. He reviews and edits every guide in this library. NPI 1104323203.