Provider Demographics
NPI:1619597671
Name:EISENBACH, HARRY
Entity Type:Individual
Prefix:
First Name:HARRY
Middle Name:
Last Name:EISENBACH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9312 SMOKETREE LN
Mailing Address - Street 2:
Mailing Address - City:VILLA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:92861-1011
Mailing Address - Country:US
Mailing Address - Phone:805-236-6587
Mailing Address - Fax:
Practice Address - Street 1:9312 SMOKETREE LN
Practice Address - Street 2:
Practice Address - City:VILLA PARK
Practice Address - State:CA
Practice Address - Zip Code:92861-1011
Practice Address - Country:US
Practice Address - Phone:805-236-6587
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-20
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA30600207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine