MEDICARE: MR. RICKY DWAYNE LATHAM MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RC0000X	Cardiovascular Disease Physician	M6887	ID
2	207RC0000X	Cardiovascular Disease Physician	MD170342	OR

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	060053550	OTHER		RAILROAD MEDICARE, RRM
14	1134041	OTHER		MEDICARE-CIGNA, MC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	000010005099	OTHER		BLUE SHIELD OF ID, BS
4	DZ692	OTHER		BLUE CROSS OF ID SE, BC2
5	M6887	OTHER	ID	ID
6	000010005099	OTHER		BLUE SHIELD OF ID S, BS2
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
8	111489100	OTHER		WY/EDS CONSULTEC, INC WYM
9	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
10	DZ692	OTHER		BLUE CROSS OF IDAHO, BC
11	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
12	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
13	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1477553139
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RICKY DWAYNE LATHAM MD

Provider Business Mailing Address
First Line	:	1775 THOMPSON RD
Second Line	:
City	:	COOS BAY
State	:	OR
Zip	:	97420-2125
Country	:	US
Telephone Number	:	541-266-4650
Fax Number	:	541-266-4659

Provider Business Practice Location Address
First Line	:	2001 VALENICA DRIVE
Second Line	:	SUITE 201
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404
Country	:	US
Telephone Number	:	208-524-9400
Fax Number	:	208-524-9401

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/26/2005
Last Update Date	:	02/13/2019

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