Provider Demographics
NPI:1255518486
Name:EICHELBAUM, EHRENTRAUD JOHANNA (MD)
Entity type:Individual
Prefix:
First Name:EHRENTRAUD
Middle Name:JOHANNA
Last Name:EICHELBAUM
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 1:1113 LATTIMORE DR
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-9032
Mailing Address - Country:US
Mailing Address - Phone:941-779-4869
Mailing Address - Fax:
Practice Address - Street 1:212 S FLORIDA ST
Practice Address - Street 2:
Practice Address - City:BUSHNELL
Practice Address - State:FL
Practice Address - Zip Code:33513-6703
Practice Address - Country:US
Practice Address - Phone:352-793-2441
Practice Address - Fax:352-793-3282
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-30
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL238000185246ZS0410X
PR18573208D00000X
FLME140028208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist