Provider Demographics
NPI:1043280886
Name:BRUBAKER, LATHA MARY (MD)
Entity type:Individual
Prefix:DR
First Name:LATHA
Middle Name:MARY
Last Name:BRUBAKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5080 SPECTRUM DR
Mailing Address - Street 2:SUITE 1200 WEST
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-4648
Mailing Address - Country:US
Mailing Address - Phone:800-232-3550
Mailing Address - Fax:
Practice Address - Street 1:12345 KATY FWY
Practice Address - Street 2:SUITE 200
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77079-1503
Practice Address - Country:US
Practice Address - Phone:281-679-5600
Practice Address - Fax:281-679-6510
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-24
Last Update Date:2009-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00041537207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8322117Medicaid
WAH74314Medicare UPIN
WA8322117Medicaid
TX00Y409Medicare PIN