Healthcare Provider Details

I. General information

NPI: 1679922462
Provider Name (Legal Business Name): JERRAD HADA PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2016
Last Update Date: 07/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 FLYNN ST
ALVA OK
73717-2240
US

IV. Provider business mailing address

520 FLYNN ST
ALVA OK
73717-2240
US

V. Phone/Fax

Practice location:
  • Phone: 580-327-3331
  • Fax: 580-327-3314
Mailing address:
  • Phone: 580-327-3331
  • Fax: 580-327-3314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number5162
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT5162
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: