Provider Demographics
NPI:1184688798
Name:LATAIF, LOUIS JR (MD)
Entity Type:Individual
Prefix:
First Name:LOUIS
Middle Name:
Last Name:LATAIF
Suffix:JR
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 1:11 JOHN MADDOX DR NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1413
Mailing Address - Country:US
Mailing Address - Phone:706-295-3992
Mailing Address - Fax:706-378-5582
Practice Address - Street 1:11 JOHN MADDOX DR NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1413
Practice Address - Country:US
Practice Address - Phone:706-295-3992
Practice Address - Fax:706-378-5582
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042331207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00708947BMedicaid
GAG28436Medicare UPIN
GA00708947BMedicaid