Provider Demographics
NPI:1346253796
Name:LATZKO, PAUL (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:LATZKO
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 1:103 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:WELLSBORO
Mailing Address - State:PA
Mailing Address - Zip Code:16901-1358
Mailing Address - Country:US
Mailing Address - Phone:570-724-1010
Mailing Address - Fax:570-724-3970
Practice Address - Street 1:103 WEST AVE
Practice Address - Street 2:
Practice Address - City:WELLSBORO
Practice Address - State:PA
Practice Address - Zip Code:16901-1358
Practice Address - Country:US
Practice Address - Phone:570-724-1010
Practice Address - Fax:570-724-3970
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD029391E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001137510Medicaid
PA453112Medicare ID - Type Unspecified
PA001137510Medicaid