MEDICARE: PAUL E. LATER M.D.

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	2084N0400X	Neurology Physician	01040003A	IN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	130006860	OTHER	IN	RR MEDICARE

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	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1689671166
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAUL E. LATER M.D.

Provider Business Mailing Address
First Line	:	7956 W JEFFERSON BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-4140
Country	:	US
Telephone Number	:	260-436-2416
Fax Number	:	260-436-9662

Provider Business Practice Location Address
First Line	:	7956 W JEFFERSON BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-4140
Country	:	US
Telephone Number	:	260-436-2416
Fax Number	:	260-436-9662

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

Provider Enumeration Date	:	06/30/2005
Last Update Date	:	12/28/2010

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Directions to “ PAUL E. LATER M.D.” Practice Location

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