Provider Demographics
NPI:1689853350
Name:MARVIN LATCHANA MD PC
Entity Type:Organization
Organization Name:MARVIN LATCHANA MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:ESHBAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-239-6731
Mailing Address - Street 1:G1071 N BALLENGER HWY
Mailing Address - Street 2:SUITE 206
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48504-4453
Mailing Address - Country:US
Mailing Address - Phone:810-234-1651
Mailing Address - Fax:810-234-5959
Practice Address - Street 1:G1071 N BALLENGER HWY
Practice Address - Street 2:SUITE 206
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48504-4453
Practice Address - Country:US
Practice Address - Phone:810-234-1651
Practice Address - Fax:810-234-5959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-30
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301037681207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2099844Medicaid
MI0255276Medicare PIN
MIB45891Medicare UPIN