Individual
MR. MARK A. LATTA
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
O.D.
Contact information
Practice address
CORNER OF ROUTE N12 AND N7, FORT DEFIANCE, AZ 86504
(928) 729-8925
Mailing address
4140 MARLA DR NE, ALBUQUERQUE, NM 87109-1983
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
2728TG
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
410039483
RAILROAD MEDICARE
TX
01
—
89X292
BC/BS
TX
Enumeration date
10/19/2005
Last updated
06/13/2019
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