Healthcare Provider Details

I. General information

NPI: 1528196326
Provider Name (Legal Business Name): GRACE G LAT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6599 FOOTHILL BLVD.
OAKLAND CA
94605
US

IV. Provider business mailing address

2709 CHERRY BLOSSOM WAY
UNION CITY CA
94587-4911
US

V. Phone/Fax

Practice location:
  • Phone: 510-567-5700
  • Fax:
Mailing address:
  • Phone: 510-429-0933
  • Fax: 510-429-0960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberA5590
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: