Provider Demographics
NPI:1720097942
Name:ROSENTHAL, LAUREL M (MD)
Entity Type:Individual
Prefix:
First Name:LAUREL
Middle Name:M
Last Name:ROSENTHAL
Suffix:
Gender:F
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:P.O. BOX 277
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:12932-0277
Mailing Address - Country:US
Mailing Address - Phone:518-873-3002
Mailing Address - Fax:518-873-2005
Practice Address - Street 1:15 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:AU SABLE FORKS
Practice Address - State:NY
Practice Address - Zip Code:12912-0897
Practice Address - Country:US
Practice Address - Phone:518-647-8164
Practice Address - Fax:518-647-2127
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY136958207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY080084134OtherRAILROAD MEDICARE
NY01770098Medicaid
B01505Medicare UPIN