Provider Demographics
NPI:1386268720
Name:BRUCE D. LATHAM, D.O.,P.A.
Entity type:Organization
Organization Name:BRUCE D. LATHAM, D.O.,P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:D
Authorized Official - Last Name:LATHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:603-901-1042
Mailing Address - Street 1:PO BOX 123
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:NH
Mailing Address - Zip Code:03818-0123
Mailing Address - Country:US
Mailing Address - Phone:603-901-1042
Mailing Address - Fax:603-901-1092
Practice Address - Street 1:66 MAIN ST
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:NH
Practice Address - Zip Code:03818-6163
Practice Address - Country:US
Practice Address - Phone:603-901-1042
Practice Address - Fax:603-901-1092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-02
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty