Provider Demographics
NPI:1477884161
Name:LATA, KUSUM (MD)
Entity Type:Individual
Prefix:
First Name:KUSUM
Middle Name:
Last Name:LATA
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 1:600 COFFEE RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-4201
Mailing Address - Country:US
Mailing Address - Phone:209-521-6097
Mailing Address - Fax:
Practice Address - Street 1:1801 E MARCH LN
Practice Address - Street 2:#A-170
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210-6629
Practice Address - Country:US
Practice Address - Phone:209-951-9885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-20
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA 110487207R00000X
CAA110487207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine