Healthcare Provider Details

I. General information

NPI: 1306883814
Provider Name (Legal Business Name): VANIKA LATH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22341 W 8 MILE RD STE 201
DETROIT MI
48219-1217
US

IV. Provider business mailing address

PO BOX 321061
DETROIT MI
48232-1061
US

V. Phone/Fax

Practice location:
  • Phone: 313-966-3222
  • Fax:
Mailing address:
  • Phone: 248-543-8070
  • Fax: 248-543-9005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number4301073216
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: