Individual
MR. RICKY DWAYNE LATHAM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
2001 VALENICA DRIVE, SUITE 201, IDAHO FALLS, ID 83404
(208) 524-9400
(208) 524-9401
Mailing address
1775 THOMPSON RD, COOS BAY, OR 97420-2125
(541) 266-4650
(541) 266-4659
Taxonomy
Speciality
Code
Description
License number
State
207RC0000X
Cardiovascular Disease Physician
M6887
ID
207RC0000X
Cardiovascular Disease Physician
Primary
MD170342
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010005099
BLUE SHIELD OF ID, BS
—
01
—
000353200
EDS- MEDICAID, EDS
—
05
—
000353200
—
ID
01
—
0031512
MONTANA MEDICAID, MEM
—
01
—
060053550
RAILROAD MEDICARE, RRM
—
01
—
111489100
MEDICAID WYOMING, MWY
—
01
—
1134041
MEDICARE-CIGNA, MC
—
05
—
500680039
—
OR
01
—
8318842
MEDICAID OF WA, MD-W
—
01
—
DZ692
BLUE CROSS OF ID SE, BC2
—
01
—
M6887
ID
ID
Enumeration date
07/26/2005
Last updated
02/13/2019
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