Provider Demographics
NPI:1104076769
Name:LADIKA, DOUGLAS JOHN (PA-C)
Entity type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:JOHN
Last Name:LADIKA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:DOUG
Other - Middle Name:
Other - Last Name:LADIKA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2705 N LEBANON ST STE 305
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:IN
Mailing Address - Zip Code:46052-8622
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:151 E BOW ST
Practice Address - Street 2:
Practice Address - City:THORNTOWN
Practice Address - State:IN
Practice Address - Zip Code:46071
Practice Address - Country:US
Practice Address - Phone:765-436-2400
Practice Address - Fax:765-436-7375
Is Sole Proprietor?:No
Enumeration Date:2008-09-19
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000987A363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300004507Medicaid