Provider Demographics
NPI:1205866258
Name:EYZAGUIRRE, MARIO EDUARDO (MD)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:EDUARDO
Last Name:EYZAGUIRRE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5626 SANDBURG AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92122-4132
Mailing Address - Country:US
Mailing Address - Phone:619-260-7046
Mailing Address - Fax:619-686-3843
Practice Address - Street 1:4077 5TH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2105
Practice Address - Country:US
Practice Address - Phone:619-260-7046
Practice Address - Fax:619-686-3843
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA425722080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE92777Medicare UPIN