Provider Demographics
NPI:1699080002
Name:LATHA MEDICAL PC
Entity type:Organization
Organization Name:LATHA MEDICAL PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THULASI
Authorized Official - Middle Name:SWARNA LATHA
Authorized Official - Last Name:DIVI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-366-1115
Mailing Address - Street 1:19953 CONANT ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48234-1334
Mailing Address - Country:US
Mailing Address - Phone:313-366-1115
Mailing Address - Fax:313-366-1116
Practice Address - Street 1:19953 CONANT ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48234-1334
Practice Address - Country:US
Practice Address - Phone:313-366-1115
Practice Address - Fax:313-366-1116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-10
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301062122207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty