Provider Demographics
NPI:1508885716
Name:LATREILLE, WILLIAM R JR (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:R
Last Name:LATREILLE
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 1:412 STATE ROUTE 37
Mailing Address - Street 2:
Mailing Address - City:HOGANSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13655-3109
Mailing Address - Country:US
Mailing Address - Phone:518-358-3141
Mailing Address - Fax:
Practice Address - Street 1:412 STATE ROUTE 37
Practice Address - Street 2:
Practice Address - City:HOGANSBURG
Practice Address - State:NY
Practice Address - Zip Code:13655
Practice Address - Country:US
Practice Address - Phone:518-358-3141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY142278207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYC58920Medicare UPIN