Provider Demographics
NPI:1356302491
Name:LATHAM, BRUCE D (DO)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:D
Last Name:LATHAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 123
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:NH
Mailing Address - Zip Code:03818-0123
Mailing Address - Country:US
Mailing Address - Phone:603-901-1042
Mailing Address - Fax:603-901-1092
Practice Address - Street 1:66 MAIN ST
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:NH
Practice Address - Zip Code:03818-6163
Practice Address - Country:US
Practice Address - Phone:603-901-1042
Practice Address - Fax:603-901-1092
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-29
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH12799207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHBL3666368OtherDEA
NHRE8264Medicare ID - Type Unspecified
NHBL3666368OtherDEA