Provider Demographics
NPI:1316936164
Name:EUSEBIO, EMMANUEL J (MD)
Entity type:Individual
Prefix:DR
First Name:EMMANUEL
Middle Name:J
Last Name:EUSEBIO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 SE 164TH AVE DEPT 358
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-8004
Mailing Address - Country:US
Mailing Address - Phone:360-729-1462
Mailing Address - Fax:360-729-3104
Practice Address - Street 1:PEACEHEALTH MEDICAL GROUP
Practice Address - Street 2:4545 CORDATA PARKWAY, SUITE 1F
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226
Practice Address - Country:US
Practice Address - Phone:360-738-2200
Practice Address - Fax:360-752-5679
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00030270103K00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1083229Medicaid
WAF75304Medicare UPIN
WAAB34812Medicare ID - Type Unspecified