Provider Demographics
NPI:1790798544
Name:LATHAM, BERNICE GRANT (MD)
Entity Type:Individual
Prefix:
First Name:BERNICE
Middle Name:GRANT
Last Name:LATHAM
Suffix:
Gender:F
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 26965
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23261-6965
Mailing Address - Country:US
Mailing Address - Phone:804-780-3008
Mailing Address - Fax:804-780-3014
Practice Address - Street 1:505 W LEIGH ST
Practice Address - Street 2:SUITE 301
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23220-3200
Practice Address - Country:US
Practice Address - Phone:804-780-3008
Practice Address - Fax:804-780-3014
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101023261207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5671051Medicaid
VA082936518Medicare PIN
VA5671051Medicaid