Healthcare Provider Details

I. General information

NPI: 1477553139
Provider Name (Legal Business Name): RICKY DWAYNE LATHAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2005
Last Update Date: 02/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 VALENICA DRIVE SUITE 201
IDAHO FALLS ID
83404
US

IV. Provider business mailing address

1775 THOMPSON RD
COOS BAY OR
97420-2125
US

V. Phone/Fax

Practice location:
  • Phone: 208-524-9400
  • Fax: 208-524-9401
Mailing address:
  • Phone: 541-266-4650
  • Fax: 541-266-4659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberM6887
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMD170342
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: