1467690552 NPI number — LAWRENCE D EISENHAUER MD INC LAWRENCE D EISENHAUER M D OFFICER

Table of content: (NPI 1467690552)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467690552 NPI number — LAWRENCE D EISENHAUER MD INC LAWRENCE D EISENHAUER M D OFFICER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAWRENCE D EISENHAUER MD INC LAWRENCE D EISENHAUER M D OFFICER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467690552
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/02/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
320 SANTA FE DR
Provider Second Line Business Mailing Address:
SUITE LL4
Provider Business Mailing Address City Name:
ENCINITAS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92024-5138
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-753-8413
Provider Business Mailing Address Fax Number:
760-753-5351

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
320 SANTA FE DR
Provider Second Line Business Practice Location Address:
SUITE LL4
Provider Business Practice Location Address City Name:
ENCINITAS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92024-5138
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-753-8413
Provider Business Practice Location Address Fax Number:
760-753-5351
Provider Enumeration Date:
01/27/2009

Additional Information

Authorized Official

Authorized Official Last Name:
EISENHAUER
Authorized Official First Name:
LAWRENCE
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
760-753-8413

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  G36375 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1083773246 . This is a "TYPE 1 NPI" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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