Provider Demographics
NPI:1871221150
Name:LATHAM, DAMIAN
Entity type:Individual
Prefix:
First Name:DAMIAN
Middle Name:
Last Name:LATHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3112 FALKLAND RD
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75007-3513
Mailing Address - Country:US
Mailing Address - Phone:618-367-3455
Mailing Address - Fax:
Practice Address - Street 1:4045 W 15TH ST
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-5891
Practice Address - Country:US
Practice Address - Phone:972-479-5923
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-12
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2157440208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation