Provider Demographics
NPI:1609055698
Name:ELLIOTT EISENBUD, MD INC.
Entity Type:Organization
Organization Name:ELLIOTT EISENBUD, MD INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-966-6139
Mailing Address - Street 1:6600 MERCY CT STE 110
Mailing Address - Street 2:
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-3150
Mailing Address - Country:US
Mailing Address - Phone:916-966-5404
Mailing Address - Fax:916-966-0932
Practice Address - Street 1:6600 MERCY CT STE 110
Practice Address - Street 2:
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628-3150
Practice Address - Country:US
Practice Address - Phone:916-966-5404
Practice Address - Fax:916-966-0932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-26
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG23760207R00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty