Healthcare Provider Details

I. General information

NPI: 1689623001
Provider Name (Legal Business Name): MERCEDES LAT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 11/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 FAMILY PRACTICE DR
KINGSTON NY
12401-6449
US

IV. Provider business mailing address

1 FAMILY PRACTICE DR
KINGSTON NY
12401-6449
US

V. Phone/Fax

Practice location:
  • Phone: 845-339-9055
  • Fax: 845-339-2310
Mailing address:
  • Phone: 845-338-6400
  • Fax: 845-339-7288

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number123826
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: