Provider Demographics
NPI:1396075636
Name:JADHAV, LATHA (MD)
Entity type:Individual
Prefix:
First Name:LATHA
Middle Name:
Last Name:JADHAV
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LATHA
Other - Middle Name:
Other - Last Name:BALLEM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:715 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07514-3406
Mailing Address - Country:US
Mailing Address - Phone:973-279-2294
Mailing Address - Fax:
Practice Address - Street 1:715 BROADWAY
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07514-3406
Practice Address - Country:US
Practice Address - Phone:973-279-2294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-08
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08647400208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics