Provider Demographics
NPI:1578606190
Name:LATHAM, PHILIP BRUCE (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:BRUCE
Last Name:LATHAM
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 1:138 LEADER AVE
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40508-3215
Mailing Address - Country:US
Mailing Address - Phone:859-255-7910
Mailing Address - Fax:859-257-7899
Practice Address - Street 1:135 E MAXWELL ST
Practice Address - Street 2:SUITE 200
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40508-2640
Practice Address - Country:US
Practice Address - Phone:859-323-6211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY23186208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64231863Medicaid
KY64231863Medicaid
C68562Medicare UPIN