Basic Information
| Provider Information | |||||||||
| NPI: | 1992281711 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLUMENTHAL | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | LOUIS | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11511 SHADOW CREEK PKWY | ||||||||
| Address2: | |||||||||
| City: | PEARLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775847298 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7134420000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6300 GARTH RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | BAYTOWN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775217669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7134421240 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2018 | ||||||||
| LastUpdateDate: | 06/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 740330 | TX | N | Nursing Service Providers | Registered Nurse | 363LP2300X | AP137975 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 423081502 | 05 | TX | MEDICAID | 423081501 | 05 | TX | MEDICAID |