Provider Demographics
NPI:1053585711
Name:WHITLATCH, LYMAN WILLIAM JR (MD, PHD)
Entity type:Individual
Prefix:
First Name:LYMAN
Middle Name:WILLIAM
Last Name:WHITLATCH
Suffix:JR
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2625 E DIVISADERO ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93721-1431
Mailing Address - Country:US
Mailing Address - Phone:559-443-2682
Mailing Address - Fax:559-443-2681
Practice Address - Street 1:202 W WILLOW AVE
Practice Address - Street 2:SUITE 305
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291-6238
Practice Address - Country:US
Practice Address - Phone:559-320-0530
Practice Address - Fax:559-320-0539
Is Sole Proprietor?:No
Enumeration Date:2008-04-14
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA108303207T00000X, 207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1841218583Medicaid
CA1841218583Medicaid