Basic Information
| Provider Information | |||||||||
| NPI: | 1124069059 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VAD | ||||||||
| FirstName: | LATA | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3801 NW 63RD ST | ||||||||
| Address2: | SUITE 160 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731161921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4058580600 | ||||||||
| FaxNumber: | 4058580602 | ||||||||
| Practice Location | |||||||||
| Address1: | 2129 SW 59TH ST | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731197024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056856671 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2006 | ||||||||
| LastUpdateDate: | 09/05/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 13502 | OK | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 100019370A | 05 | OK | MEDICAID |