Healthcare Provider Details

I. General information

NPI: 1265743793
Provider Name (Legal Business Name): JULIE M LATA DO PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2010
Last Update Date: 06/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 HARRINGTON ST
MOUNT CLEMENS MI
48043-2920
US

IV. Provider business mailing address

12175 NOONAN CT
UTICA MI
48315-5871
US

V. Phone/Fax

Practice location:
  • Phone: 586-493-8101
  • Fax:
Mailing address:
  • Phone: 586-323-3022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number15101016802
License Number StateMI

VIII. Authorized Official

Name: JULIE M LATA
Title or Position: OWNER
Credential: DO
Phone: 586-323-3022