Provider Demographics
NPI:1215956602
Name:LATTA, RALPH I (MD)
Entity type:Individual
Prefix:
First Name:RALPH
Middle Name:I
Last Name:LATTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1228
Mailing Address - Street 2:501 N DUQUOIN
Mailing Address - City:BENTON
Mailing Address - State:IL
Mailing Address - Zip Code:62812-5228
Mailing Address - Country:US
Mailing Address - Phone:618-435-5362
Mailing Address - Fax:618-438-2613
Practice Address - Street 1:501 N DUQUOIN
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:IL
Practice Address - Zip Code:62812-5228
Practice Address - Country:US
Practice Address - Phone:618-435-5362
Practice Address - Fax:618-438-2613
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036114358207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00329229OtherRR MEDICARE NUMBER
ILCG5564OtherRR GROUP NUMBER
IL036114358Medicaid
ILP00329229OtherRR MEDICARE NUMBER