Provider Demographics
NPI:1306883814
Name:LATH, VANIKA (MD)
Entity type:Individual
Prefix:
First Name:VANIKA
Middle Name:
Last Name:LATH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 321061
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48232-1061
Mailing Address - Country:US
Mailing Address - Phone:248-543-8070
Mailing Address - Fax:248-543-9005
Practice Address - Street 1:22341 W 8 MILE RD
Practice Address - Street 2:STE 201
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48219-1217
Practice Address - Country:US
Practice Address - Phone:313-966-3222
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301073216207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4781696Medicaid
MI4781696Medicaid