Provider Demographics
NPI:1962533810
Name:JERRY LATHAM OD PC
Entity type:Organization
Organization Name:JERRY LATHAM OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:LATHAM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:817-571-6688
Mailing Address - Street 1:2600 HARWOOD RD
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76021-3700
Mailing Address - Country:US
Mailing Address - Phone:817-571-6688
Mailing Address - Fax:817-571-6906
Practice Address - Street 1:2600 HARWOOD RD
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76021-3700
Practice Address - Country:US
Practice Address - Phone:817-571-6688
Practice Address - Fax:817-571-6906
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2009-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00910ZMedicare ID - Type UnspecifiedGROUP PRACTICE
TX0A3227Medicare PIN