Provider Demographics
NPI:1902863293
Name:LATTIMORE, GARY J (OD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:J
Last Name:LATTIMORE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 S WOODRUFF AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-5200
Mailing Address - Country:US
Mailing Address - Phone:208-522-6271
Mailing Address - Fax:208-522-7217
Practice Address - Street 1:501 S WOODRUFF AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-5200
Practice Address - Country:US
Practice Address - Phone:208-522-6271
Practice Address - Fax:208-522-7217
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-28
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID0505152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0002441400Medicaid
IDT44300Medicare UPIN
ID5190784Medicare ID - Type Unspecified