Provider Demographics
NPI:1912369950
Name:BLUMENTHAL, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BLUMENTHAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:267 W HILLCREST DR
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-4211
Mailing Address - Country:US
Mailing Address - Phone:805-497-1694
Mailing Address - Fax:
Practice Address - Street 1:267 W HILLCREST DR
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-4211
Practice Address - Country:US
Practice Address - Phone:805-497-1694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-28
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA152647207NS0135X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program