Provider Demographics
NPI:1437118163
Name:BROOKENTHAL, KEITH R (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:R
Last Name:BROOKENTHAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:24712 HERMOSILLA COURT
Mailing Address - Street 2:
Mailing Address - City:CALABASAS
Mailing Address - State:CA
Mailing Address - Zip Code:91302
Mailing Address - Country:US
Mailing Address - Phone:818-223-9568
Mailing Address - Fax:
Practice Address - Street 1:5353 BALBOA BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-2804
Practice Address - Country:US
Practice Address - Phone:818-789-9449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA79821207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH70096Medicare UPIN