Healthcare Provider Details

I. General information

NPI: 1144332727
Provider Name (Legal Business Name): WILEY J LATHAM MD AND BERNICE G LATHAM MD PARTNERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 10/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 WEST LEIGH ST SUITE 301
RICHMOND VA
23220
US

IV. Provider business mailing address

PO BOX 15483
RICHMOND VA
23227-0000
US

V. Phone/Fax

Practice location:
  • Phone: 804-780-3008
  • Fax: 804-780-3014
Mailing address:
  • Phone: 804-780-3008
  • Fax: 804-780-3014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101023261
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number0101023313
License Number StateVA

VIII. Authorized Official

Name: DR. WILEY JACOB LATHAM III
Title or Position: PARTNER
Credential: MD
Phone: 804-780-3008