1477553139 NPI number — MR. RICKY DWAYNE LATHAM MD

Table of content: DR. CHRISTAL L WEST M.D. (NPI 1427016856)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477553139 NPI number — MR. RICKY DWAYNE LATHAM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LATHAM
Provider First Name:
RICKY
Provider Middle Name:
DWAYNE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477553139
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/13/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1775 THOMPSON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COOS BAY
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97420-2125
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-266-4650
Provider Business Mailing Address Fax Number:
541-266-4659

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2001 VALENICA DRIVE
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
IDAHO FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-524-9400
Provider Business Practice Location Address Fax Number:
208-524-9401
Provider Enumeration Date:
07/26/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  M6887 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0000X , with the licence number: MD170342 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 111489100 . This is a "MEDICAID WYOMING, MWY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000010005099 . This is a "BLUE SHIELD OF ID, BS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 060053550 . This is a "RAILROAD MEDICARE, RRM" identifier . This identifiers is of the category "OTHER".
  • Identifier: DZ692 . This is a "BLUE CROSS OF ID SE, BC2" identifier . This identifiers is of the category "OTHER".
  • Identifier: M6887 . This is a "ID" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000010005099 . This is a "BLUE SHIELD OF ID S, BS2" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000353200 . This is a "EDS- MEDICAID, EDS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 111489100 . This is a "WY/EDS CONSULTEC, INC WYM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8318842 . This is a "MEDICAID OF WA, MD-W" identifier . This identifiers is of the category "OTHER".
  • Identifier: DZ692 . This is a "BLUE CROSS OF IDAHO, BC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000353200 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 500680039 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0031512 . This is a "MONTANA MEDICAID, MEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1134041 . This is a "MEDICARE-CIGNA, MC" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2026 www.npivalidator.com