Provider Demographics
NPI:1578570248
Name:LATTIMER, JON KINGSLEY (MD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:KINGSLEY
Last Name:LATTIMER
Suffix:
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:PO BOX 5308
Mailing Address - Street 2:
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96745-5308
Mailing Address - Country:US
Mailing Address - Phone:808-323-2136
Mailing Address - Fax:808-323-2138
Practice Address - Street 1:81-6627 MAMALAHOA HIGHWAY SUITE 106
Practice Address - Street 2:
Practice Address - City:KEALAKEKUA
Practice Address - State:HI
Practice Address - Zip Code:96750
Practice Address - Country:US
Practice Address - Phone:808-323-2136
Practice Address - Fax:808-323-2138
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI3814208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI04591301Medicaid
HIC98830Medicare UPIN