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General NPI Number Information
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NPI Number | 1477553139
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Entity Type | Individual
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Provider Name | RICKY DWAYNE LATHAM MD
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Gender | Male
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Dates
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Enumeration Date | 07/26/2005
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Last Update Date | 02/13/2019
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Provider Practice Location Address
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Address Line | 2001 VALENICA DRIVE SUITE 201
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City | IDAHO FALLS
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State | ID
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Zip | 83404
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Country | US
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Telephone | 208-524-9400
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Fax | 208-524-9401
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Provider Business Mailing Address
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Address Line | 1775 THOMPSON RD
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City | COOS BAY
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State | OR
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Zip | 97420-2125
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Country | US
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Telephone | 541-266-4650
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Fax | 541-266-4659
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RC0000X
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Taxonomy Name | Cardiovascular Disease Physician
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License Number | M6887
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 207RC0000X
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Taxonomy Name | Cardiovascular Disease Physician
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License Number | MD170342
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License Number State | OR
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