Provider Demographics
NPI:1780647115
Name:LATZMAN, GORDON (MD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:
Last Name:LATZMAN
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 1:888 WHITE PLAINS RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611-4552
Mailing Address - Country:US
Mailing Address - Phone:203-459-4594
Mailing Address - Fax:203-459-0362
Practice Address - Street 1:888 WHITE PLAINS RD
Practice Address - Street 2:SUITE 110
Practice Address - City:TRUMBULL
Practice Address - State:CT
Practice Address - Zip Code:06611-4552
Practice Address - Country:US
Practice Address - Phone:203-459-4594
Practice Address - Fax:203-459-0362
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2013-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT042961207RG0100X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001214585Medicaid
CTH42711Medicare UPIN
CT110009549Medicare ID - Type Unspecified
CT490000231Medicare ID - Type UnspecifiedFCEC MEDICARE