Healthcare Provider Details

I. General information

NPI: 1619154895
Provider Name (Legal Business Name): IGOR LATICH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2008
Last Update Date: 06/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 YORK STREET, T-209 YALE-NEW HAVEN HOSPITAL
NEW HAVEN CT
06510
US

IV. Provider business mailing address

111 ARDMORE RD
WEST HARTFORD CT
06119-1203
US

V. Phone/Fax

Practice location:
  • Phone: 203-688-2259
  • Fax: 203-688-5599
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number051089
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: