Provider Demographics
NPI:1235188053
Name:LATHAM, ANGELA C (MD)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:C
Last Name:LATHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5012 S US HIGHWAY 75 STE 300
Mailing Address - Street 2:ATTN BILLING
Mailing Address - City:DENISON
Mailing Address - State:TX
Mailing Address - Zip Code:75020-4589
Mailing Address - Country:US
Mailing Address - Phone:903-416-6025
Mailing Address - Fax:
Practice Address - Street 1:5012 S US HIGHWAY 75
Practice Address - Street 2:SUITE 225
Practice Address - City:DENISON
Practice Address - State:TX
Practice Address - Zip Code:75020-4587
Practice Address - Country:US
Practice Address - Phone:903-416-6025
Practice Address - Fax:903-416-6195
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2018-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ6007207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX116416202Medicaid
TX85Y235Medicare PIN
TX116416202Medicaid