Provider Demographics
NPI:1356469365
Name:MITCHELL C LATTER MD INC A PROF CORP
Entity Type:Organization
Organization Name:MITCHELL C LATTER MD INC A PROF CORP
Other - Org Name:MITCHELL C LATTER MD INC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:CURTIS
Authorized Official - Last Name:LATTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-799-9588
Mailing Address - Street 1:1499 HUNTINGTON DRIVE
Mailing Address - Street 2:SUITE 508
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-5464
Mailing Address - Country:US
Mailing Address - Phone:626-799-9588
Mailing Address - Fax:626-799-9339
Practice Address - Street 1:1499 HUNTINGTON DRIVE
Practice Address - Street 2:SUITE 508
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-5464
Practice Address - Country:US
Practice Address - Phone:626-799-9588
Practice Address - Fax:626-799-9339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG40013332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1255411625OtherNPI TYPE 1
CA00G400131Medicaid
CA1219870002Medicare NSC
CAB56712Medicare UPIN
CAG40013AMedicare ID - Type Unspecified