Provider Demographics
NPI:1396266516
Name:LATOURRETTE, EVAN THOMAS (DPM)
Entity type:Individual
Prefix:MR
First Name:EVAN
Middle Name:THOMAS
Last Name:LATOURRETTE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1231 DEER PARK AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11703-3104
Mailing Address - Country:US
Mailing Address - Phone:631-667-0388
Mailing Address - Fax:631-968-7705
Practice Address - Street 1:382 ROSEVALE AVE
Practice Address - Street 2:
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-3069
Practice Address - Country:US
Practice Address - Phone:631-667-0388
Practice Address - Fax:631-968-7705
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-28
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN007080-1213E00000X, 213ES0103X, 213ES0131X, 213EP1101X
NYN007080213E00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB1386739514Medicaid
NYETINAD01Medicaid