Provider Demographics
NPI:1437178548
Name:LATHAM, PHILLIP LANE JR (MD)
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:LANE
Last Name:LATHAM
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 1:560 CONSTITUTION DR
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29154-8175
Mailing Address - Country:US
Mailing Address - Phone:803-775-4469
Mailing Address - Fax:803-775-4981
Practice Address - Street 1:560 CONSTITUTION DR
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29154-8175
Practice Address - Country:US
Practice Address - Phone:803-775-4469
Practice Address - Fax:803-775-4981
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCBL4905850207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC144490Medicaid
E72837Medicare UPIN
6391Medicare ID - Type Unspecified