Healthcare Provider Details

I. General information

NPI: 1790068716
Provider Name (Legal Business Name): MFISHAJI LADD JR. BHRS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2011
Last Update Date: 09/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57533 MOCCASIN TRAIL RD
PRAGUE OK
74864-1143
US

IV. Provider business mailing address

57533 MOCCASIN TRAIL RD
PRAGUE OK
74864-1143
US

V. Phone/Fax

Practice location:
  • Phone: 405-567-0054
  • Fax: 405-567-0055
Mailing address:
  • Phone: 405-567-0054
  • Fax: 405-567-0055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: