Provider Demographics
NPI:1083710008
Name:EISENBAUM, MARC (MD)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:
Last Name:EISENBAUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3700 JOSEPH SIEWICK DR
Mailing Address - Street 2:SUITE 203
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-1744
Mailing Address - Country:US
Mailing Address - Phone:703-758-8313
Mailing Address - Fax:
Practice Address - Street 1:3700 JOSEPH SIEWICK DR
Practice Address - Street 2:SUITE 203
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1744
Practice Address - Country:US
Practice Address - Phone:703-758-8313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101040504207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B93818Medicare UPIN
161958Medicare ID - Type Unspecified