Healthcare Provider Details

I. General information

NPI: 1316966815
Provider Name (Legal Business Name): ELYSE RAE EISENBERG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 03/10/2025
Certification Date: 03/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 FARMERS LN STE 10
SANTA ROSA CA
95405-6710
US

IV. Provider business mailing address

6114 LA SALLE AVE 438
OAKLAND CA
94611-2802
US

V. Phone/Fax

Practice location:
  • Phone: 707-523-3375
  • Fax: 866-870-0815
Mailing address:
  • Phone: 707-523-3375
  • Fax: 866-870-0815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberG64542
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberG64542
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: