Provider Demographics
NPI:1679922462
Name:HADA, JERRAD (PT)
Entity Type:Individual
Prefix:
First Name:JERRAD
Middle Name:
Last Name:HADA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 FLYNN ST
Mailing Address - Street 2:
Mailing Address - City:ALVA
Mailing Address - State:OK
Mailing Address - Zip Code:73717-2240
Mailing Address - Country:US
Mailing Address - Phone:580-327-3331
Mailing Address - Fax:580-327-3314
Practice Address - Street 1:520 FLYNN ST
Practice Address - Street 2:
Practice Address - City:ALVA
Practice Address - State:OK
Practice Address - Zip Code:73717-2240
Practice Address - Country:US
Practice Address - Phone:580-327-3331
Practice Address - Fax:580-327-3314
Is Sole Proprietor?:No
Enumeration Date:2016-06-13
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK51622081S0010X
OKPT5162225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200693970AMedicaid