Healthcare Provider Details

I. General information

NPI: 1205866258
Provider Name (Legal Business Name): MARIO EDUARDO EYZAGUIRRE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4077 5TH AVE
SAN DIEGO CA
92103-2105
US

IV. Provider business mailing address

5626 SANDBURG AVE
SAN DIEGO CA
92122-4132
US

V. Phone/Fax

Practice location:
  • Phone: 619-260-7046
  • Fax: 619-686-3843
Mailing address:
  • Phone: 619-260-7046
  • Fax: 619-686-3843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberA42572
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: