Provider Demographics
NPI:1497850598
Name:LATZ, JEFFREY D (PT)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:D
Last Name:LATZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CA
Mailing Address - Zip Code:95492-0010
Mailing Address - Country:US
Mailing Address - Phone:707-837-7980
Mailing Address - Fax:707-837-7983
Practice Address - Street 1:208 CONCOURSE BLVD STE 2
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-8210
Practice Address - Country:US
Practice Address - Phone:707-303-4992
Practice Address - Fax:707-303-4996
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2020-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT25497225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ00793ZOtherBLUE SHIELD PROV ID #
CAZZZ23118ZOtherMEDICARE GRP ID#
CA061548025OtherTIN
CAZZZ00793ZOtherBLUE SHIELD PROV ID #