Healthcare Provider Details

I. General information

NPI: 1861482564
Provider Name (Legal Business Name): LARA B EISENBERG MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 10/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1145 19TH ST NW SUITE 205
WASHINGTON DC
20036-3701
US

IV. Provider business mailing address

PO BOX 4196
COLUMBUS GA
31914-0196
US

V. Phone/Fax

Practice location:
  • Phone: 301-279-4490
  • Fax: 301-279-4489
Mailing address:
  • Phone: 301-279-4490
  • Fax: 301-279-4489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberD0054567
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: