Healthcare Provider Details

I. General information

NPI: 1154209732
Provider Name (Legal Business Name): IAN EISENBERGER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2025
Last Update Date: 08/22/2025
Certification Date: 08/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 EL CAMINO REAL
ATHERTON CA
94027-4300
US

IV. Provider business mailing address

90 E 3RD ST UNIT 309
MORGAN HILL CA
95037-3549
US

V. Phone/Fax

Practice location:
  • Phone: 716-228-8974
  • Fax:
Mailing address:
  • Phone: 716-228-8974
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number2000037817
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: