Provider Demographics
NPI:1023069812
Name:LATIMER, EARL A III (MD)
Entity type:Individual
Prefix:DR
First Name:EARL
Middle Name:A
Last Name:LATIMER
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 E 19TH ST
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-5110
Mailing Address - Country:US
Mailing Address - Phone:575-622-7600
Mailing Address - Fax:575-622-3856
Practice Address - Street 1:115 E 19TH ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5110
Practice Address - Country:US
Practice Address - Phone:575-622-7600
Practice Address - Fax:575-622-3856
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM92-93207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM07167Medicaid
E54780Medicare UPIN
NM07167Medicaid