Healthcare Provider Details

I. General information

NPI: 1518227305
Provider Name (Legal Business Name): LILADHAR KASHYAP MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2012
Last Update Date: 09/06/2022
Certification Date: 09/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 S PARK LN STE 100
ALTUS OK
73521-5731
US

IV. Provider business mailing address

1200 E PECAN ST
ALTUS OK
73521-6141
US

V. Phone/Fax

Practice location:
  • Phone: 580-379-6100
  • Fax: 580-379-6109
Mailing address:
  • Phone: 580-379-5000
  • Fax: 580-379-5509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number31320
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: