Basic Information
| Provider Information | |||||||||
| NPI: | 1003887274 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LATHAM | ||||||||
| FirstName: | MEGAN | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 5100 HWY 70 W | ||||||||
| Address2: | |||||||||
| City: | MOREHEAD CITY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285574504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2527275290 | ||||||||
| FaxNumber: | 2527270091 | ||||||||
| Practice Location | |||||||||
| Address1: | 5100 HWY 70 WEST | ||||||||
| Address2: | |||||||||
| City: | MOREHEAD CITY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285574512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2527275290 | ||||||||
| FaxNumber: | 2527270091 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2006 | ||||||||
| LastUpdateDate: | 01/25/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1912 | NC | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 89093P8 | 05 | NC | MEDICAID | 0922U | 01 | NC | BLUE CROSS BLUE SHIELD | OTHER |