Healthcare Provider Details

I. General information

NPI: 1063749802
Provider Name (Legal Business Name): JOSEPH MARK EISENBERG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2009
Last Update Date: 09/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 NE 8TH ST 3RD FLOOR, EAST COUNTY HEALTH CENTER
GRESHAM OR
97030
US

IV. Provider business mailing address

600 NE 8TH ST 3RD FLOOR, EAST COUNTY HEALTH CENTER
GRESHAM OR
97030
US

V. Phone/Fax

Practice location:
  • Phone: 503-988-5155
  • Fax: 503-988-5185
Mailing address:
  • Phone: 503-988-5155
  • Fax: 503-988-5185

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA110000
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD154918
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: