Healthcare Provider Details

I. General information

NPI: 1073932091
Provider Name (Legal Business Name): ERIC JACOB FICHTENBAUM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2014
Last Update Date: 01/25/2022
Certification Date: 08/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 E MAIN ST STE 220
COLUMBUS OH
43215-5369
US

IV. Provider business mailing address

PO BOX 31309
LOS ANGELES CA
90031-0309
US

V. Phone/Fax

Practice location:
  • Phone: 614-544-9670
  • Fax: 614-544-9671
Mailing address:
  • Phone: 323-276-3707
  • Fax: 513-558-3474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberA162397
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number35.1396815
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: