Provider Demographics
NPI:1962463273
Name:LATOS, DERRICK L (MD)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:L
Last Name:LATOS
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 1:58 16TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-3660
Mailing Address - Country:US
Mailing Address - Phone:304-242-7751
Mailing Address - Fax:304-242-7254
Practice Address - Street 1:58 16TH ST
Practice Address - Street 2:SUITE 500
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-3660
Practice Address - Country:US
Practice Address - Phone:304-242-7751
Practice Address - Fax:304-242-7254
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV10953207RN0300X
OH35051747L207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV10953BOtherHPUOV
OH0344854Medicaid
WV0077242000Medicaid
WV0433043Medicare ID - Type Unspecified
OH0344854Medicaid
WV0077242000Medicaid