Basic Information
| Provider Information | |||||||||
| NPI: | 1396266516 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LATOURRETTE | ||||||||
| FirstName: | EVAN | ||||||||
| MiddleName: | THOMAS | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1231 DEER PARK AVE | ||||||||
| Address2: | |||||||||
| City: | NORTH BABYLON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117033104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6316670388 | ||||||||
| FaxNumber: | 6319687705 | ||||||||
| Practice Location | |||||||||
| Address1: | 382 ROSEVALE AVE | ||||||||
| Address2: | |||||||||
| City: | RONKONKOMA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117793069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6316670388 | ||||||||
| FaxNumber: | 6319687705 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2017 | ||||||||
| LastUpdateDate: | 07/15/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | N007080-1 | NY | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213E00000X | N007080 | NY | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213ES0103X | N007080-1 | NY | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213ES0131X | N007080-1 | NY | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot Surgery | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 213EP1101X | N007080-1 | NY | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Primary Podiatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | B1386739514 | 05 | NY | MEDICAID | ETINAD01 | 05 | NY | MEDICAID |