Basic Information
| Provider Information | |||||||||
| NPI: | 1801894555 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LATTANZI | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | C. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2038 | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN HOME | ||||||||
| State: | AR | ||||||||
| PostalCode: | 726542038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8704247070 | ||||||||
| FaxNumber: | 8704246616 | ||||||||
| Practice Location | |||||||||
| Address1: | 628 HOSPITAL DR | ||||||||
| Address2: | GROUND FLOOR, SUITE A | ||||||||
| City: | MOUNTAIN HOME | ||||||||
| State: | AR | ||||||||
| PostalCode: | 726532953 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8704254402 | ||||||||
| FaxNumber: | 8604372236 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2005 | ||||||||
| LastUpdateDate: | 12/15/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 035831 | CT | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RH0003X | E-9749 | AR | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207R00000X | 035831 | CT | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RX0202X | 035831 | CT | N | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 001358317 | 05 | CT | MEDICAID |