Provider Demographics
NPI:1477553139
Name:LATHAM, RICKY DWAYNE (MD)
Entity Type:Individual
Prefix:MR
First Name:RICKY
Middle Name:DWAYNE
Last Name:LATHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1775 THOMPSON RD
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2125
Mailing Address - Country:US
Mailing Address - Phone:541-266-4650
Mailing Address - Fax:541-266-4659
Practice Address - Street 1:2001 VALENICA DRIVE
Practice Address - Street 2:SUITE 201
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404
Practice Address - Country:US
Practice Address - Phone:208-524-9400
Practice Address - Fax:208-524-9401
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6887207RC0000X
ORMD170342207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
111489100OtherMEDICAID WYOMING, MWY
000010005099OtherBLUE SHIELD OF ID, BS
060053550OtherRAILROAD MEDICARE, RRM
DZ692OtherBLUE CROSS OF ID SE, BC2
IDM6887OtherID
000010005099OtherBLUE SHIELD OF ID S, BS2
000353200OtherEDS- MEDICAID, EDS
111489100OtherWY/EDS CONSULTEC, INC WYM
8318842OtherMEDICAID OF WA, MD-W
DZ692OtherBLUE CROSS OF IDAHO, BC
ID000353200Medicaid
OR500680039Medicaid
0031512OtherMONTANA MEDICAID, MEM
1134041OtherMEDICARE-CIGNA, MC
ORR178917Medicare PIN
OR93-0635514OtherNORTH BEND MEDICAL CENTER GROUP TAX ID
ID000353200Medicaid
OR500680039Medicaid
ORR178917Medicare PIN