Provider Demographics
NPI:1649805847
Name:BISRAM, LATCHMAN
Entity type:Individual
Prefix:DR
First Name:LATCHMAN
Middle Name:
Last Name:BISRAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10943 142ND ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11435-5505
Mailing Address - Country:US
Mailing Address - Phone:347-358-6244
Mailing Address - Fax:
Practice Address - Street 1:11902 ROCKAWAY BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH OZONE PARK
Practice Address - State:NY
Practice Address - Zip Code:11420-2422
Practice Address - Country:US
Practice Address - Phone:718-529-9503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-08
Last Update Date:2020-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY066580183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist