Provider Demographics
NPI:1558353904
Name:EULBERG, DOUGLAS (PA-C)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:EULBERG
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45434-5807
Mailing Address - Country:US
Mailing Address - Phone:937-427-8018
Mailing Address - Fax:937-424-2581
Practice Address - Street 1:3075 GOVERNORS PLACE BLVD
Practice Address - Street 2:SUITE 120
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-1323
Practice Address - Country:US
Practice Address - Phone:937-424-2580
Practice Address - Fax:937-424-2581
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-19
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50-000152363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHEUPA 17312Medicare ID - Type Unspecified