Provider Demographics
NPI:1528151404
Name:LATY, MARK (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:LATY
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 1:16260 VENTURA BLVD STE 630
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2255
Mailing Address - Country:US
Mailing Address - Phone:747-998-0387
Mailing Address - Fax:
Practice Address - Street 1:16260 VENTURA BLVD STE 630
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2255
Practice Address - Country:US
Practice Address - Phone:747-998-0387
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA857232084P0800X
FLME912442084A0401X, 2084A0401X
TN404752084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ92069ZOtherCOUNTY OF SANTA CRUZ MEDICARE GROUP PTAN#
CAFHC70042FOtherCOUNTY OF SANTA CRUZ MEDI-CAL GROUP PROVIDER#
CAZZZ91892ZOtherCOUNTY OF SANTA CRUZ MEDICARE GROUP PTAN#
CAZZZ91892ZOtherCOUNTY OF SANTA CRUZ MEDICARE GROUP PTAN#