Provider Demographics
NPI:1861482564
Name:EISENBERG, LARA B (MD)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:B
Last Name:EISENBERG
Suffix:
Gender:F
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:PO BOX 4196
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31914-0196
Mailing Address - Country:US
Mailing Address - Phone:301-279-4490
Mailing Address - Fax:301-279-4489
Practice Address - Street 1:1145 19TH ST NW
Practice Address - Street 2:SUITE 205
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20036-3701
Practice Address - Country:US
Practice Address - Phone:301-279-4490
Practice Address - Fax:301-279-4489
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00545672085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
F92385Medicare UPIN
DC003168G23Medicare PIN