Provider Demographics
NPI:1427163146
Name:LATHAM, GEORGIA (MD)
Entity type:Individual
Prefix:
First Name:GEORGIA
Middle Name:
Last Name:LATHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:393 N MAIN ST
Mailing Address - Street 2:P.O. BOX 1209
Mailing Address - City:SPARTA
Mailing Address - State:NC
Mailing Address - Zip Code:28675-8896
Mailing Address - Country:US
Mailing Address - Phone:336-372-7575
Mailing Address - Fax:336-372-7540
Practice Address - Street 1:393 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:NC
Practice Address - Zip Code:28675-8896
Practice Address - Country:US
Practice Address - Phone:336-372-7575
Practice Address - Fax:336-372-7540
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9300197207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89012PJMedicaid
NC89012PJMedicaid
2308111Medicare ID - Type Unspecified