Organization
GARY J LATTIMORE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. GARY J LATTIMORE O.D. (OPTOMETRIST)
(208) 522-6271
Entity
Organization
Contact information
Practice address
501 S WOODRUFF AVE, IDAHO FALLS, ID 83401-5200
(208) 522-6271
(208) 522-7217
Mailing address
501 S WOODRUFF AVE, IDAHO FALLS, ID 83401-5200
(208) 522-6271
(208) 522-7217
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010015231
BLUESHIELD OF IDAHO
ID
05
—
002441400
—
IN
01
—
V0724
BLUE CROSS OF IDAHO
ID
Enumeration date
07/12/2007
Last updated
02/28/2008
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