Provider Demographics
NPI:1902061674
Name:BLUMENTHAL, JACK JOSEPH (DO)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:JOSEPH
Last Name:BLUMENTHAL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 THELMA ST
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77581-7081
Mailing Address - Country:US
Mailing Address - Phone:281-485-3361
Mailing Address - Fax:281-485-3361
Practice Address - Street 1:2550 THELMA ST
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77581-7081
Practice Address - Country:US
Practice Address - Phone:281-485-3361
Practice Address - Fax:281-485-3361
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-22
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD5276208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery