Provider Demographics
NPI:1689092462
Name:LAUBHAM, MATTHEW P (DO)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:P
Last Name:LAUBHAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 ACKERMAN RD STE 2120
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1559
Mailing Address - Country:US
Mailing Address - Phone:614-688-7150
Mailing Address - Fax:
Practice Address - Street 1:6515 PULLMAN DR
Practice Address - Street 2:
Practice Address - City:LEWIS CENTER
Practice Address - State:OH
Practice Address - Zip Code:43035-7380
Practice Address - Country:US
Practice Address - Phone:614-688-7150
Practice Address - Fax:614-688-7155
Is Sole Proprietor?:No
Enumeration Date:2014-03-31
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1689092462208000000X, 207RC0000X, 207R00000X
OH34.014554207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0417412Medicaid