Provider Demographics
NPI:1841204856
Name:LATHAM, JOHN M (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
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 1:1111 LUCERNE TER
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1016
Mailing Address - Country:US
Mailing Address - Phone:407-540-3700
Mailing Address - Fax:407-540-3720
Practice Address - Street 1:1111 LUCERNE TER
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1016
Practice Address - Country:US
Practice Address - Phone:407-540-3700
Practice Address - Fax:407-540-3720
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME34660207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL048334600Medicaid
FL110191932OtherRAILROAD MEDICARE
D85761Medicare UPIN
FL048334600Medicaid
FL47350XMedicare PIN