Basic Information
| Provider Information | |||||||||
| NPI: | 1184616831 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LATHAM | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1950 OLD GALLOWS RD STE 520 | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221823970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038478899 | ||||||||
| FaxNumber: | 5712236780 | ||||||||
| Practice Location | |||||||||
| Address1: | 2600 HARWOOD RD | ||||||||
| Address2: | |||||||||
| City: | BEDFORD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760213700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8175716688 | ||||||||
| FaxNumber: | 8175716906 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2005 | ||||||||
| LastUpdateDate: | 11/25/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2727TG | TX | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.