Provider Demographics
NPI:1174612550
Name:WIRTHLIN, LAURIE S (MD)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:S
Last Name:WIRTHLIN
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 1:2800 HARRIS ST
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95503-4809
Mailing Address - Country:US
Mailing Address - Phone:707-445-8416
Mailing Address - Fax:707-445-4182
Practice Address - Street 1:2800 HARRIS ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95503-4809
Practice Address - Country:US
Practice Address - Phone:707-445-8416
Practice Address - Fax:707-445-4182
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC53534208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
E47699Medicare UPIN