Provider Demographics
NPI:1003436296
Name:LATHAM, IAN G (MD)
Entity Type:Individual
Prefix:DR
First Name:IAN
Middle Name:G
Last Name:LATHAM
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 1:2450 RIVERSIDE AVENUE SOUTH
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55454
Mailing Address - Country:US
Mailing Address - Phone:612-273-9848
Mailing Address - Fax:
Practice Address - Street 1:2450 RIVERSIDE AVENUE SOUTH
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454
Practice Address - Country:US
Practice Address - Phone:612-273-9848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-17
Last Update Date:2023-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN69943207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine