Provider Demographics
NPI:1043675051
Name:WAREHAM, ROBERT (LAT)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:WAREHAM
Suffix:
Gender:M
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 FOREST WIND CIR
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:TX
Mailing Address - Zip Code:77316-6846
Mailing Address - Country:US
Mailing Address - Phone:281-844-7689
Mailing Address - Fax:
Practice Address - Street 1:105 FOREST WIND CIR
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:TX
Practice Address - Zip Code:77316-6846
Practice Address - Country:US
Practice Address - Phone:281-844-7689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-17
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT4698174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist