Provider Demographics
NPI:1831398643
Name:GARY J LATTIMORE
Entity type:Organization
Organization Name:GARY J LATTIMORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:J
Authorized Official - Last Name:LATTIMORE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-522-6271
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-12
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010015231OtherBLUESHIELD OF IDAHO
IN002441400Medicaid
IDV0724OtherBLUE CROSS OF IDAHO
IDV0724OtherBLUE CROSS OF IDAHO