Healthcare Provider Details

I. General information

NPI: 1922379965
Provider Name (Legal Business Name): EVANN E EISENBERG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2012
Last Update Date: 05/01/2020
Certification Date: 05/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 S FAIR OAKS AVE STE 215
PASADENA CA
91105-2613
US

IV. Provider business mailing address

3452 E FOOTHILL BLVD STE 130
PASADENA CA
91107-6006
US

V. Phone/Fax

Practice location:
  • Phone: 626-793-4139
  • Fax: 626-793-4324
Mailing address:
  • Phone: 626-793-2885
  • Fax: 626-793-6262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number114010
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberA125493
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: