Healthcare Provider Details

I. General information

NPI: 1104203793
Provider Name (Legal Business Name): ERIC ANDREW EISEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2015
Last Update Date: 08/17/2023
Certification Date: 08/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1231 116TH AVE NE STE 930
BELLEVUE WA
98004-3804
US

IV. Provider business mailing address

1231 116TH AVE NE STE 930
BELLEVUE WA
98004-3804
US

V. Phone/Fax

Practice location:
  • Phone: 425-688-1916
  • Fax: 425-688-1901
Mailing address:
  • Phone: 425-688-1916
  • Fax: 425-688-1901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberMD61047604
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License NumberMD61047604
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: