Healthcare Provider Details

I. General information

NPI: 1700041290
Provider Name (Legal Business Name): CLARKE T LATIMER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2008
Last Update Date: 05/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1080 PEACHTREE ST NE STE 12
ATLANTA GA
30309
US

IV. Provider business mailing address

1080 PEACHTREE ST NE STE 12
ATLANTA GA
30309-6857
US

V. Phone/Fax

Practice location:
  • Phone: 404-253-3660
  • Fax:
Mailing address:
  • Phone: 404-253-3660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number079003
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: