1104076769 NPI number — MR. DOUGLAS JOHN LADIKA PA-C

Table of content: MR. DOUGLAS JOHN LADIKA PA-C (NPI 1104076769)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104076769 NPI number — MR. DOUGLAS JOHN LADIKA PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LADIKA
Provider First Name:
DOUGLAS
Provider Middle Name:
JOHN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LADIKA
Provider Other First Name:
DOUG
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1104076769
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/28/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2705 N LEBANON ST STE 305
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEBANON
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46052-8622
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
151 E BOW ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
THORNTOWN
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46071
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-436-2400
Provider Business Practice Location Address Fax Number:
765-436-7375
Provider Enumeration Date:
09/19/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  10000987A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 300004507 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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