1134496896 NPI number — DR. ROBERT WILBUT LAURIDSEN PH.D.

Table of content: DR. ROBERT WILBUT LAURIDSEN PH.D. (NPI 1134496896)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134496896 NPI number — DR. ROBERT WILBUT LAURIDSEN PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LAURIDSEN
Provider First Name:
ROBERT
Provider Middle Name:
WILBUT
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134496896
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/23/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19450 REDBERRY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS GATOS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95030-2928
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
408-398-4006
Provider Business Mailing Address Fax Number:
408-356-2143

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
455 LOS GATOS BLVD
Provider Second Line Business Practice Location Address:
#202
Provider Business Practice Location Address City Name:
LOS GATOS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95032-5523
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
408-356-2141
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/23/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  PSY 5763 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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