Provider Demographics
NPI:1053311555
Name:LATIMER, ROBERT A W (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:A W
Last Name:LATIMER
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:703-368-3161
Mailing Address - Fax:703-368-2498
Practice Address - Street 1:8640 SUDLEY RD
Practice Address - Street 2:SUITE 203
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-4420
Practice Address - Country:US
Practice Address - Phone:703-368-3161
Practice Address - Fax:703-368-2498
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101042121207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1053311555Medicaid
VAVAA113268Medicare PIN
B06027Medicare UPIN
VA1053311555Medicaid
VA5617499Medicare ID - Type Unspecified