Provider Demographics
NPI:1801894555
Name:LATTANZI, STEPHEN C (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:C
Last Name:LATTANZI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2038
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72654-2038
Mailing Address - Country:US
Mailing Address - Phone:870-424-7070
Mailing Address - Fax:870-424-6616
Practice Address - Street 1:628 HOSPITAL DR
Practice Address - Street 2:GROUND FLOOR, SUITE A
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-2953
Practice Address - Country:US
Practice Address - Phone:870-425-4402
Practice Address - Fax:860-437-2236
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT035831207RH0003X, 207R00000X, 207RX0202X
ARE-9749207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001358317Medicaid
CTF77227Medicare UPIN
CT110008543Medicare PIN