Healthcare Provider Details

I. General information

NPI: 1609055698
Provider Name (Legal Business Name): ELLIOTT EISENBUD, MD INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2007
Last Update Date: 10/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6600 MERCY CT STE 110
FAIR OAKS CA
95628-3150
US

IV. Provider business mailing address

6600 MERCY CT STE 110
FAIR OAKS CA
95628-3150
US

V. Phone/Fax

Practice location:
  • Phone: 916-966-5404
  • Fax: 916-966-0932
Mailing address:
  • Phone: 916-966-5404
  • Fax: 916-966-0932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG23760
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberG23760
License Number StateCA

VIII. Authorized Official

Name: TIFFANY RUSTIN
Title or Position: OFFICE MANAGER
Credential:
Phone: 916-966-6139