Provider Demographics
NPI:1891738555
Name:LATIF, WALEAD (DO)
Entity Type:Individual
Prefix:DR
First Name:WALEAD
Middle Name:
Last Name:LATIF
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 VALLEY STREAM PKWY
Mailing Address - Street 2:#100
Mailing Address - City:MALVERN
Mailing Address - State:PA
Mailing Address - Zip Code:19355-1407
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2401 MORRIS AVE
Practice Address - Street 2:SUITE W112
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-5745
Practice Address - Country:US
Practice Address - Phone:908-686-0123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY229086207R00000X
NJ25MB08675400207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0216097Medicaid
NJ168823VBMMedicare PIN
NJ0216097Medicaid