Provider Demographics
NPI:1164674214
Name:LADRA, MATTHEW MICHAEL
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:MICHAEL
Last Name:LADRA
Suffix:
Gender:M
Credentials:
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 64474
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4474
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:401 N BROADWAY ST
Practice Address - Street 2:WEINBERG 1440
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0019
Practice Address - Country:US
Practice Address - Phone:410-614-1642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-21
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAML600400412085R0001X
MDD809922085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAML60040041OtherWASHINGTON STATE MEDICAL LICENSE