Provider Demographics
NPI:1528253846
Name:HILTON, LATISHA MECHELE (DO)
Entity type:Individual
Prefix:DR
First Name:LATISHA
Middle Name:MECHELE
Last Name:HILTON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:LATISHA
Other - Middle Name:MECHELE
Other - Last Name:BOWMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:716 SPRING ST.
Mailing Address - Street 2:SUITE 204
Mailing Address - City:WISE
Mailing Address - State:VA
Mailing Address - Zip Code:24293
Mailing Address - Country:US
Mailing Address - Phone:276-328-8910
Mailing Address - Fax:276-328-4318
Practice Address - Street 1:716 SPRING STREET
Practice Address - Street 2:SUITE 204
Practice Address - City:WISE
Practice Address - State:VA
Practice Address - Zip Code:24293
Practice Address - Country:US
Practice Address - Phone:276-329-8910
Practice Address - Fax:276-328-4318
Is Sole Proprietor?:No
Enumeration Date:2007-09-10
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102202078207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00819102OtherRR MEDICARE
VA1528253846Medicaid
KY7100077100Medicaid
VAC10456OtherTRAILBLAZER
VAC10456Medicare UPIN
VAC10456OtherTRAILBLAZER