Provider Demographics
NPI:1588832448
Name:MITCHELL C LATTER M D INC A PROF CORP
Entity Type:Organization
Organization Name:MITCHELL C LATTER M D INC A PROF CORP
Other - Org Name:MITCHELL C LATTER MD INC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:CURTIS
Authorized Official - Last Name:LATTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-799-9588
Mailing Address - Street 1:375 HUNTINGTON DR
Mailing Address - Street 2:SUITE F
Mailing Address - City:SAN MARINO
Mailing Address - State:CA
Mailing Address - Zip Code:91108-2357
Mailing Address - Country:US
Mailing Address - Phone:626-799-9588
Mailing Address - Fax:626-799-9339
Practice Address - Street 1:375 HUNTINGTON DR
Practice Address - Street 2:SUITE F
Practice Address - City:SAN MARINO
Practice Address - State:CA
Practice Address - Zip Code:91108-2357
Practice Address - Country:US
Practice Address - Phone:626-799-9588
Practice Address - Fax:626-799-9339
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MITCHELL C LATTER M D INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-13
Last Update Date:2009-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG40013207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G400131Medicaid
CA00G400131Medicaid
G40013AMedicare PIN
1219870002Medicare NSC