Healthcare Provider Details

I. General information

NPI: 1174612550
Provider Name (Legal Business Name): LAURIE S WIRTHLIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 02/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 HARRIS ST
EUREKA CA
95503-4809
US

IV. Provider business mailing address

2800 HARRIS ST
EUREKA CA
95503-4809
US

V. Phone/Fax

Practice location:
  • Phone: 707-445-8416
  • Fax: 707-445-4182
Mailing address:
  • Phone: 707-445-8416
  • Fax: 707-445-4182

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberC53534
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: