Healthcare Provider Details

I. General information

NPI: 1962533810
Provider Name (Legal Business Name): JERRY LATHAM OD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 03/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 HARWOOD RD
BEDFORD TX
76021-3700
US

IV. Provider business mailing address

2600 HARWOOD RD
BEDFORD TX
76021-3700
US

V. Phone/Fax

Practice location:
  • Phone: 817-571-6688
  • Fax: 817-571-6906
Mailing address:
  • Phone: 817-571-6688
  • Fax: 817-571-6906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateTX

VIII. Authorized Official

Name: JERRY L LATHAM
Title or Position: OWNER
Credential: O.D.
Phone: 817-571-6688