Provider Demographics
NPI:1659402238
Name:BLUMENTHAL, MARK FREDERICK (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:FREDERICK
Last Name:BLUMENTHAL
Suffix:
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 1:12878 MANCHESTER RD # C
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-1803
Mailing Address - Country:US
Mailing Address - Phone:314-966-6100
Mailing Address - Fax:
Practice Address - Street 1:12878 MANCHESTER RD
Practice Address - Street 2:SUITE C
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-1803
Practice Address - Country:US
Practice Address - Phone:314-966-6100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR7718174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOA11529Medicare UPIN
MO000011562Medicare ID - Type Unspecified