Healthcare Provider Details

I. General information

NPI: 1932179587
Provider Name (Legal Business Name): DONALD R EBERSOLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 12/10/2024
Certification Date: 12/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8609 EVERGREEN WAY
EVERETT WA
98208-2619
US

IV. Provider business mailing address

814 BAINBRIDGE PL
GOSHEN IN
46526-5527
US

V. Phone/Fax

Practice location:
  • Phone: 425-258-1830
  • Fax:
Mailing address:
  • Phone: 574-536-2541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01042385A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: